Provider Demographics
NPI:1639702251
Name:RUBLE, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:RUBLE
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 1:5564 SUMMER RIDGE WAY APT A
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-1053
Mailing Address - Country:US
Mailing Address - Phone:219-877-8241
Mailing Address - Fax:
Practice Address - Street 1:600 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1354
Practice Address - Country:US
Practice Address - Phone:269-615-8209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
IN1-22-62673103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician