Provider Demographics
NPI:1669795761
Name:DR. LAURIE FAIRALL-RUETER, LLC
Entity type:Organization
Organization Name:DR. LAURIE FAIRALL-RUETER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRALL-RUETER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:904-463-2284
Mailing Address - Street 1:4400 MARSH LANDING BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-1287
Mailing Address - Country:US
Mailing Address - Phone:904-463-2284
Mailing Address - Fax:904-543-7755
Practice Address - Street 1:4400 MARSH LANDING BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-1287
Practice Address - Country:US
Practice Address - Phone:904-463-2284
Practice Address - Fax:904-543-7755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-04
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36593103TC0700X
GAPY003739103TC0700X
FLPY 7675103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty