Provider Demographics
NPI:1043693096
Name:RUDERSTALLER, THOMAS (LPC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:RUDERSTALLER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E SOUTHERN AVE
Mailing Address - Street 2:SUITE 735
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-5691
Mailing Address - Country:US
Mailing Address - Phone:480-804-0326
Mailing Address - Fax:480-302-7884
Practice Address - Street 1:2120 S MCCLINTOCK DR
Practice Address - Street 2:STE. 105
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-2692
Practice Address - Country:US
Practice Address - Phone:480-804-0326
Practice Address - Fax:480-302-7884
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-15817101YP2500X
AZLAC-14239101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ069063Medicaid