Provider Demographics
NPI:1366583346
Name:RUTA, KELLY SULLIVAN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SULLIVAN
Last Name:RUTA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 WAKE FOREST BUSINESS PARK
Mailing Address - Street 2:SUITE D
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-6523
Mailing Address - Country:US
Mailing Address - Phone:919-435-1347
Mailing Address - Fax:
Practice Address - Street 1:833 WAKE FOREST BUSINESS PARK
Practice Address - Street 2:SUITE D
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6523
Practice Address - Country:US
Practice Address - Phone:919-435-1347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-10
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC051714001041C0700X
NCC0063741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical