Provider Demographics
NPI:1801447966
Name:RUTHERFORD, IRWIN CLYDE JR (LPC)
Entity type:Individual
Prefix:MR
First Name:IRWIN
Middle Name:CLYDE
Last Name:RUTHERFORD
Suffix:JR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 KENTSHIRE LANE
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005
Mailing Address - Country:US
Mailing Address - Phone:229-401-8431
Mailing Address - Fax:
Practice Address - Street 1:109 OSIGIAN BLVD STE 400
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8925
Practice Address - Country:US
Practice Address - Phone:229-401-8431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008881101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional