1578732632 NPI number — MAXINE A RUDDOCK PHD P A

Table of content: (NPI 1578732632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578732632 NPI number — MAXINE A RUDDOCK PHD P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAXINE A RUDDOCK PHD P A
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COMPREHENSIVE PSYCHOLOGICAL & ASSESSMENT SERVICES
Provider Other Organization Name Type Code:
3
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:
1578732632
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2511 DORA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAVARES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32778-4977
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-508-5399
Provider Business Mailing Address Fax Number:
917-677-7121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2511 DORA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAVARES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32778-4977
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-508-5399
Provider Business Practice Location Address Fax Number:
917-677-7121
Provider Enumeration Date:
02/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RUDDOCK
Authorized Official First Name:
MAXINE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
352-508-5399

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  PY7658 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: PY7658 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004100303 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004100300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008487400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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