1528629326 NPI number — MRS. LIZA G RUDROFF M.ED., TVI

Table of content: MRS. LIZA G RUDROFF M.ED., TVI (NPI 1528629326)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528629326 NPI number — MRS. LIZA G RUDROFF M.ED., TVI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUDROFF
Provider First Name:
LIZA
Provider Middle Name:
G
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.ED., TVI
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:
1528629326
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
85 WASHINGTON AVE
Provider Second Line Business Mailing Address:
LWR
Provider Business Mailing Address City Name:
KENMORE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14217-1905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-777-0870
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
85 WASHINGTON AVE
Provider Second Line Business Practice Location Address:
LWR
Provider Business Practice Location Address City Name:
KENMORE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14217-1905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-777-0870
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/24/2019

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: 174400000X , with the licence number:  477735101 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 1374401191 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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