Provider Demographics
NPI:1780754069
Name:RUYLE, ROBERTA LOUISE (PHD)
Entity type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:LOUISE
Last Name:RUYLE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MRS
Other - First Name:ROBERTA
Other - Middle Name:LOUISE
Other - Last Name:RUYLE-MALADY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3535 PARK ST
Mailing Address - Street 2:SUITE 101B
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-3736
Mailing Address - Country:US
Mailing Address - Phone:231-737-4444
Mailing Address - Fax:231-737-5555
Practice Address - Street 1:3535 PARK ST
Practice Address - Street 2:SUITE 101B
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-3736
Practice Address - Country:US
Practice Address - Phone:231-737-4444
Practice Address - Fax:231-737-5555
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801033346104100000X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP11980002Medicare ID - Type UnspecifiedMEDICARE NUMBER
MI0P11980Medicare PIN
MI8008791920Medicare UPIN