Provider Demographics
NPI:1417906850
Name:RUTT, GLORIA DIANE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:DIANE
Last Name:RUTT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:GLORIA
Other - Middle Name:D
Other - Last Name:RUTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:2305 COULTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009
Mailing Address - Country:US
Mailing Address - Phone:307-286-4106
Mailing Address - Fax:307-632-6588
Practice Address - Street 1:2305 COULTER DRIVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009
Practice Address - Country:US
Practice Address - Phone:307-286-4106
Practice Address - Fax:307-632-6588
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY422103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY123535400Medicaid