Provider Demographics
NPI:1053183459
Name:RUTZ, THERESA MICHELLE
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MICHELLE
Last Name:RUTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 W AINSLIE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-3349
Mailing Address - Country:US
Mailing Address - Phone:630-334-1357
Mailing Address - Fax:
Practice Address - Street 1:2923 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-7886
Practice Address - Country:US
Practice Address - Phone:800-206-8136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health