Provider Demographics
NPI:1487768248
Name:FAIRALL-RUETER, LAURIE S (PSYD)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:S
Last Name:FAIRALL-RUETER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 MARSH LANDING BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-1287
Mailing Address - Country:US
Mailing Address - Phone:904-463-2284
Mailing Address - Fax:904-543-7755
Practice Address - Street 1:4400 MARSH LANDING BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-1287
Practice Address - Country:US
Practice Address - Phone:904-463-2284
Practice Address - Fax:904-543-7755
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPY003739103T00000X
TX36593103T00000X
FLPY 7675103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist