Provider Demographics
NPI:1073090973
Name:RUDD, KATRINA (LICSW)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:RUDD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 PARK TER APT A
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02474-1227
Mailing Address - Country:US
Mailing Address - Phone:207-272-8201
Mailing Address - Fax:
Practice Address - Street 1:101 1ST AVE STE 6
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1160
Practice Address - Country:US
Practice Address - Phone:781-693-5141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1202031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty