Provider Demographics
NPI:1083080477
Name:RUGSAKEN, DEREK (LPCC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:RUGSAKEN
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 151
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:NM
Mailing Address - Zip Code:87527-0151
Mailing Address - Country:US
Mailing Address - Phone:765-748-6139
Mailing Address - Fax:
Practice Address - Street 1:1200 N PASEO DE ONATE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2687
Practice Address - Country:US
Practice Address - Phone:765-748-6139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NMCCMH0219111101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health