Provider Demographics
NPI:1457858573
Name:SATHASIVAM-RUECKERT, NINA (PHD)
Entity Type:Individual
Prefix:DR
First Name:NINA
Middle Name:
Last Name:SATHASIVAM-RUECKERT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 W NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53295-0001
Mailing Address - Country:US
Mailing Address - Phone:414-384-2000
Mailing Address - Fax:
Practice Address - Street 1:ZABLOCKI VA MEDICAL CENTER 5000 WEST NATIONAL AVENUE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53295
Practice Address - Country:US
Practice Address - Phone:414-384-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3393-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist