1699969139 NPI number — CYNTHIA RUBLAITUS LCSW

Table of content: CYNTHIA RUBLAITUS LCSW (NPI 1699969139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699969139 NPI number — CYNTHIA RUBLAITUS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUBLAITUS
Provider First Name:
CYNTHIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699969139
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 BOARDWALK SPRINGS PL
Provider Second Line Business Mailing Address:
SUITE 111
Provider Business Mailing Address City Name:
O FALLON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63368-4778
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-695-4554
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ONE MEMORIAL DRIVE
Provider Second Line Business Practice Location Address:
SENIOR RENEWAL PROGRAM-OLIN WING
Provider Business Practice Location Address City Name:
ALTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62002-6722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-463-7518
Provider Business Practice Location Address Fax Number:
618-463-7896
Provider Enumeration Date:
08/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  149.011456 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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