Provider Demographics
NPI:1689395063
Name:FENLON, RUTHLENE DUERO
Entity Type:Individual
Prefix:
First Name:RUTHLENE
Middle Name:DUERO
Last Name:FENLON
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 1:1010 S GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3434
Mailing Address - Country:US
Mailing Address - Phone:231-645-2766
Mailing Address - Fax:
Practice Address - Street 1:1000 S GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2404
Practice Address - Country:US
Practice Address - Phone:231-645-2766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851115556101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)