Provider Demographics
NPI:1669481511
Name:RUETHER, KEITH DWAINE (MA)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:DWAINE
Last Name:RUETHER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 S LANCASTER RD
Mailing Address - Street 2:MENTAL HEALTH 116A
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216-7167
Mailing Address - Country:US
Mailing Address - Phone:214-857-0835
Mailing Address - Fax:214-857-0902
Practice Address - Street 1:4500 S LANCASTER RD
Practice Address - Street 2:MENTAL HEALTH 116A
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7167
Practice Address - Country:US
Practice Address - Phone:214-857-0835
Practice Address - Fax:214-857-0902
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1996103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical