Provider Demographics
NPI:1720199045
Name:RUEN, SANDRA L (MSW)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:L
Last Name:RUEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 FAIRFIELD AVE
Mailing Address - Street 2:C/O TAMARA ROLLER
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-1218
Mailing Address - Country:US
Mailing Address - Phone:260-456-4880
Mailing Address - Fax:260-456-3559
Practice Address - Street 1:2805 FAIRFIELD AVE
Practice Address - Street 2:C/O TAMARA ROLLER
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-1218
Practice Address - Country:US
Practice Address - Phone:260-456-4880
Practice Address - Fax:260-456-3559
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000946A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN13580OtherPHP
INP00449240OtherRAILROAD MEDICARE
IN100463070Medicaid
IN13580OtherPHP
INB28086Medicare UPIN