Provider Demographics
NPI:1164588745
Name:LAWRENCE G. RUFFIN
Entity Type:Organization
Organization Name:LAWRENCE G. RUFFIN
Other - Org Name:SELAH ACADEMY, INCORPORATED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AQUANATTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:219-980-7919
Mailing Address - Street 1:PO BOX 15090
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46409-5090
Mailing Address - Country:US
Mailing Address - Phone:219-980-7919
Mailing Address - Fax:
Practice Address - Street 1:1991 W 39TH CT FL 2
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-2474
Practice Address - Country:US
Practice Address - Phone:219-980-7919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041315A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200818150Medicaid