Provider Demographics
NPI:1902340136
Name:DERUITER, MARK R (MA, LLMFT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:DERUITER
Suffix:
Gender:M
Credentials:MA, LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:778 COLUMBIA AVE W
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-3028
Mailing Address - Country:US
Mailing Address - Phone:269-965-3247
Mailing Address - Fax:269-966-4135
Practice Address - Street 1:778 COLUMBIA AVE W
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-3028
Practice Address - Country:US
Practice Address - Phone:269-965-3247
Practice Address - Fax:269-966-4135
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101006710106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist