Provider Demographics
NPI:1780809400
Name:RUCKER, MINA L (MFTI)
Entity type:Individual
Prefix:MRS
First Name:MINA
Middle Name:L
Last Name:RUCKER
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3562 HIAWATHA WAY
Mailing Address - Street 2:
Mailing Address - City:ANTELOPE
Mailing Address - State:CA
Mailing Address - Zip Code:95843
Mailing Address - Country:US
Mailing Address - Phone:530-886-2835
Mailing Address - Fax:530-889-6735
Practice Address - Street 1:3562 HIAWATHA WAY
Practice Address - Street 2:
Practice Address - City:ANTELOPE
Practice Address - State:CA
Practice Address - Zip Code:95843-6216
Practice Address - Country:US
Practice Address - Phone:530-886-2835
Practice Address - Fax:530-889-6735
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFTI48846106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFTI48846OtherMFTI