Provider Demographics
NPI:1881999829
Name:RUTKOWSKI, BETH (LP, CAADC)
Entity type:Individual
Prefix:DR
First Name:BETH
Middle Name:
Last Name:RUTKOWSKI
Suffix:
Gender:F
Credentials:LP, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1247 WOODWARD AVE
Mailing Address - Street 2:APT 1010
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-2025
Mailing Address - Country:US
Mailing Address - Phone:734-395-5622
Mailing Address - Fax:
Practice Address - Street 1:8623 N WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-1137
Practice Address - Country:US
Practice Address - Phone:734-425-0636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014879103TC0700X
MIC-02694103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)