Provider Demographics
NPI:1730354895
Name:BERUBE, RONALD JOSEPH JR (MS)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:JOSEPH
Last Name:BERUBE
Suffix:JR
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W BROADWAY
Mailing Address - Street 2:SUITE 107
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-9045
Mailing Address - Country:US
Mailing Address - Phone:712-328-3700
Mailing Address - Fax:712-328-3721
Practice Address - Street 1:300 W BROADWAY
Practice Address - Street 2:SUITE 107
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-9045
Practice Address - Country:US
Practice Address - Phone:712-328-3700
Practice Address - Fax:712-328-3721
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA977101YM0800X
NE3117101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1013490Medicaid
IA0487348Medicaid