Provider Demographics
NPI:1811096381
Name:RURACK, KIMBERLY ANN (LCPC)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:RURACK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:DAMRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14 S 72ND ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-2321
Mailing Address - Country:US
Mailing Address - Phone:618-398-1898
Mailing Address - Fax:
Practice Address - Street 1:8601 W MAIN ST
Practice Address - Street 2:STE 201
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-1719
Practice Address - Country:US
Practice Address - Phone:618-394-5900
Practice Address - Fax:618-394-5909
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional