Provider Demographics
NPI:1245236835
Name:RUTLEDGE, LARRY L (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:L
Last Name:RUTLEDGE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4305
Mailing Address - Country:US
Mailing Address - Phone:814-410-8330
Mailing Address - Fax:814-410-8331
Practice Address - Street 1:111A ROOSEVELT BLOUEVARD
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15901
Practice Address - Country:US
Practice Address - Phone:814-619-4223
Practice Address - Fax:814-539-0985
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-008498-L103G00000X, 103TR0400X
PAPS008498L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
S09443Medicare UPIN
PARU005286Medicare ID - Type Unspecified