Provider Demographics
NPI:1497365969
Name:RUTTENBERG, NICOLE SUSANNE (MS, LMFTA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:SUSANNE
Last Name:RUTTENBERG
Suffix:
Gender:F
Credentials:MS, LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17129 32ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-5323
Mailing Address - Country:US
Mailing Address - Phone:206-850-6439
Mailing Address - Fax:
Practice Address - Street 1:17129 32ND AVE NE
Practice Address - Street 2:
Practice Address - City:LAKE FOREST PARK
Practice Address - State:WA
Practice Address - Zip Code:98155-5323
Practice Address - Country:US
Practice Address - Phone:206-850-6439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-08
Last Update Date:2020-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61073067106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist