Provider Demographics
NPI:1073158689
Name:RUDEZ, VANDA
Entity Type:Individual
Prefix:
First Name:VANDA
Middle Name:
Last Name:RUDEZ
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 402
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10535-0402
Mailing Address - Country:US
Mailing Address - Phone:321-424-0654
Mailing Address - Fax:
Practice Address - Street 1:3151 STONY ST
Practice Address - Street 2:
Practice Address - City:MOHEGAN LAKE
Practice Address - State:NY
Practice Address - Zip Code:10547-1913
Practice Address - Country:US
Practice Address - Phone:914-885-0110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool