Provider Demographics
NPI:1538512900
Name:DECKENBACK, EMILY RUTH (LM CPM)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:RUTH
Last Name:DECKENBACK
Suffix:
Gender:F
Credentials:LM CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 395
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-0395
Mailing Address - Country:US
Mailing Address - Phone:415-649-6262
Mailing Address - Fax:
Practice Address - Street 1:917 GREEN AVE
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-3131
Practice Address - Country:US
Practice Address - Phone:415-649-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA438176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife