Provider Demographics
NPI:1740540129
Name:RUTTAN, CARLICE CECIL II (LCSW)
Entity type:Individual
Prefix:MR
First Name:CARLICE
Middle Name:CECIL
Last Name:RUTTAN
Suffix:II
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 COLEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2217
Mailing Address - Country:US
Mailing Address - Phone:315-782-2061
Mailing Address - Fax:315-788-1529
Practice Address - Street 1:165 COLEMAN AVE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2217
Practice Address - Country:US
Practice Address - Phone:315-782-2061
Practice Address - Fax:315-788-1529
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY079048-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical