Provider Demographics
NPI:1205594900
Name:RUTHARDT, KASEY RENEE
Entity type:Individual
Prefix:
First Name:KASEY
Middle Name:RENEE
Last Name:RUTHARDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 OFFALY DR APT 5107
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-5195
Mailing Address - Country:US
Mailing Address - Phone:480-399-5898
Mailing Address - Fax:
Practice Address - Street 1:2010 OFFALY DR APT 5107
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5195
Practice Address - Country:US
Practice Address - Phone:480-399-5898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCBACB732639106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
01141999OtherCIGNA HEALTH