Provider Demographics
NPI:1497113567
Name:RUTKOWSKI, BRANDI MARIE
Entity Type:Individual
Prefix:MS
First Name:BRANDI
Middle Name:MARIE
Last Name:RUTKOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43902 WOODWARD AVE
Mailing Address - Street 2:230
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-5011
Mailing Address - Country:US
Mailing Address - Phone:248-858-8412
Mailing Address - Fax:248-858-8411
Practice Address - Street 1:43902 WOODWARD AVE
Practice Address - Street 2:230
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5011
Practice Address - Country:US
Practice Address - Phone:248-858-8412
Practice Address - Fax:248-858-8411
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016548103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical