Provider Demographics
NPI:1720118276
Name:RUTHERFORD, ALTIS BEATRICE (BA,BHRS, CM-A)
Entity Type:Individual
Prefix:MRS
First Name:ALTIS
Middle Name:BEATRICE
Last Name:RUTHERFORD
Suffix:
Gender:F
Credentials:BA,BHRS, CM-A
Other - Prefix:MRS
Other - First Name:ALTIS
Other - Middle Name:BEATRICE
Other - Last Name:RUTHERFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BA,BHRS, CM-A
Mailing Address - Street 1:PO BOX 673
Mailing Address - Street 2:
Mailing Address - City:VALLIANT
Mailing Address - State:OK
Mailing Address - Zip Code:74764-0673
Mailing Address - Country:US
Mailing Address - Phone:580-933-7031
Mailing Address - Fax:580-933-7034
Practice Address - Street 1:300 N DALTON
Practice Address - Street 2:
Practice Address - City:VALLIANT
Practice Address - State:OK
Practice Address - Zip Code:74764
Practice Address - Country:US
Practice Address - Phone:580-286-6638
Practice Address - Fax:580-286-5206
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor