Provider Demographics
NPI:1740223817
Name:RUTLIN, TAEDRA MARIE (MA PLPC)
Entity Type:Individual
Prefix:MISS
First Name:TAEDRA
Middle Name:MARIE
Last Name:RUTLIN
Suffix:
Gender:F
Credentials:MA PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 LIBERTY VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031
Mailing Address - Country:US
Mailing Address - Phone:314-838-1545
Mailing Address - Fax:
Practice Address - Street 1:14377 WOOD LAKE DRIVE
Practice Address - Street 2:SUITE 308
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017
Practice Address - Country:US
Practice Address - Phone:314-576-6493
Practice Address - Fax:314-576-7319
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002017415101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor