Basic Information
| Provider Information | |||||||||
| NPI: | 1225328347 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUDD | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3999 WIMBERLY RD | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368321512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347401688 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 917 BEVILLE RD | ||||||||
| Address2: | SUITE G | ||||||||
| City: | SOUTH DAYTONA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321191712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867564395 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2011 | ||||||||
| LastUpdateDate: | 04/11/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2315 | AL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 9353 | NC | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.