1477739944 NPI number — MRS. LISA RENEE RUDDUCK MA, CDP, LMHC

Table of content: MRS. LISA RENEE RUDDUCK MA, CDP, LMHC (NPI 1477739944)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477739944 NPI number — MRS. LISA RENEE RUDDUCK MA, CDP, LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUDDUCK
Provider First Name:
LISA
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA, CDP, LMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1477739944
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
815 9TH AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KIRKLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98033-6701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-274-6053
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10518 NE 68TH ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
KIRKLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98033-7003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-274-6053
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LH60118561 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: LH60118561 . This is a "LICENSED MENTAL HEALTH COUNSELOR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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