Provider Demographics
NPI:1083070395
Name:RUTLEDGE, CLARA
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:
Last Name:RUTLEDGE
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 1:115 GLENBROOK DR
Mailing Address - Street 2:
Mailing Address - City:CALERA
Mailing Address - State:OK
Mailing Address - Zip Code:74730-5516
Mailing Address - Country:US
Mailing Address - Phone:843-509-2759
Mailing Address - Fax:
Practice Address - Street 1:1705 N WASHINGTON AVE STE D
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2100
Practice Address - Country:US
Practice Address - Phone:580-931-3008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-04
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100728830Medicaid