Provider Demographics
NPI:1093059081
Name:MYERS-VASSELL, RUTH (LCPC, EDD,)
Entity Type:Individual
Prefix:DR
First Name:RUTH
Middle Name:
Last Name:MYERS-VASSELL
Suffix:
Gender:F
Credentials:LCPC, EDD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11920 GREGORY ST
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-1111
Mailing Address - Country:US
Mailing Address - Phone:773-401-7526
Mailing Address - Fax:708-629-0477
Practice Address - Street 1:1525 E 53RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4557
Practice Address - Country:US
Practice Address - Phone:773-401-7526
Practice Address - Fax:708-629-0477
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004976101YP2500X
103T00000X
IL2149481103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool