Provider Demographics
NPI:1982776225
Name:RUTBERG, ERIC (MA, LCPC)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:
Last Name:RUTBERG
Suffix:
Gender:M
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1082
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:ME
Mailing Address - Zip Code:04294-1082
Mailing Address - Country:US
Mailing Address - Phone:207-645-2818
Mailing Address - Fax:
Practice Address - Street 1:154 HIGH ST # 8
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:ME
Practice Address - Zip Code:04938-1958
Practice Address - Country:US
Practice Address - Phone:207-778-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC2077101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional