Provider Demographics
NPI:1013589654
Name:RUTAR, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:RUTAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 W INDIAN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85033-3326
Mailing Address - Country:US
Mailing Address - Phone:320-267-8360
Mailing Address - Fax:
Practice Address - Street 1:5806 S 35TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-4371
Practice Address - Country:US
Practice Address - Phone:320-267-8360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-008107225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOTH-008107OtherARIZONA BOARD OF OCCUPATIONAL THERAPY EXAMINERS
424259OtherTHE NATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY