Provider Demographics
NPI:1912538547
Name:STARK - REDMAN, RUTHIE LEE (LCDC)
Entity Type:Individual
Prefix:
First Name:RUTHIE
Middle Name:LEE
Last Name:STARK - REDMAN
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9001 GLACIER AVE APT 226
Mailing Address - Street 2:
Mailing Address - City:TEXAS CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77591-3017
Mailing Address - Country:US
Mailing Address - Phone:440-231-7096
Mailing Address - Fax:
Practice Address - Street 1:1100 NASA PWKY
Practice Address - Street 2:SUITE 201 A
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77598-7759
Practice Address - Country:US
Practice Address - Phone:281-904-6512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-02
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14743101YA0400X
TX14742101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101Y00000XOtherM.S. ADDICTION COUNSELOR