Provider Demographics
NPI:1073138491
Name:RUD, KYA
Entity Type:Individual
Prefix:
First Name:KYA
Middle Name:
Last Name:RUD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 178
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-0178
Mailing Address - Country:US
Mailing Address - Phone:763-412-1700
Mailing Address - Fax:763-324-8181
Practice Address - Street 1:604 1ST ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-1606
Practice Address - Country:US
Practice Address - Phone:763-412-1700
Practice Address - Fax:763-324-8181
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health