Provider Demographics
NPI:1629088398
Name:RUBNKE, ROY RONOLD (PHD)
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:RONOLD
Last Name:RUBNKE
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 1:510 FRANCIS
Mailing Address - Street 2:STE 200
Mailing Address - City:ST JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64501
Mailing Address - Country:US
Mailing Address - Phone:916-364-1501
Mailing Address - Fax:816-364-6735
Practice Address - Street 1:510 FRANCIS
Practice Address - Street 2:STE 200
Practice Address - City:ST JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64501
Practice Address - Country:US
Practice Address - Phone:916-364-1501
Practice Address - Fax:816-364-6735
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01027103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R63408Medicare UPIN