Provider Demographics
NPI:1477926160
Name:RUCKER, KWAYULYN
Entity type:Individual
Prefix:
First Name:KWAYULYN
Middle Name:
Last Name:RUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KWANJULYNN
Other - Middle Name:
Other - Last Name:NORWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:29600 LAURA RIDGE DR NW
Mailing Address - Street 2:
Mailing Address - City:HARVEST
Mailing Address - State:AL
Mailing Address - Zip Code:35749-5901
Mailing Address - Country:US
Mailing Address - Phone:248-632-6448
Mailing Address - Fax:
Practice Address - Street 1:29600 LAURA RIDGE DR NW
Practice Address - Street 2:
Practice Address - City:HARVEST
Practice Address - State:AL
Practice Address - Zip Code:35749-5901
Practice Address - Country:US
Practice Address - Phone:248-632-6448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALLPC04143101YP2500X
KY239719101YP2500X
MI6401222478101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional