Provider Demographics
NPI:1861885329
Name:RUTKAUSKAS, KRISTINA (LMSW, QIDP)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:RUTKAUSKAS
Suffix:
Gender:F
Credentials:LMSW, QIDP
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:
Other - Last Name:LUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 FULLER AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1918
Mailing Address - Country:US
Mailing Address - Phone:616-336-3909
Mailing Address - Fax:616-336-2475
Practice Address - Street 1:790 FULLER AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1918
Practice Address - Country:US
Practice Address - Phone:616-336-3909
Practice Address - Fax:616-336-2475
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010869691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical