Provider Demographics
NPI:1679604698
Name:RUEHL, MARK EDWARD (PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:RUEHL
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 1:723 N CUYLER AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1704
Mailing Address - Country:US
Mailing Address - Phone:708-848-4127
Mailing Address - Fax:
Practice Address - Street 1:1010 LAKE ST
Practice Address - Street 2:SUITE 601
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1147
Practice Address - Country:US
Practice Address - Phone:708-848-4127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical