Provider Demographics
NPI:1164908364
Name:WOLBERT, RUTH MILDRED (CP 60080400)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:MILDRED
Last Name:WOLBERT
Suffix:
Gender:F
Credentials:CP 60080400
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3629 S D ST # MS 1119
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-6813
Mailing Address - Country:US
Mailing Address - Phone:253-798-6563
Mailing Address - Fax:253-798-2935
Practice Address - Street 1:3629 S D ST # MS 1119
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-6813
Practice Address - Country:US
Practice Address - Phone:253-798-6563
Practice Address - Fax:253-798-2935
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60080400101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)