Provider Demographics
NPI:1073707147
Name:RUDEN, TIMOTHY J (PHD)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:J
Last Name:RUDEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4640 SLATER RD STE 120
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-4043
Mailing Address - Country:US
Mailing Address - Phone:651-882-5161
Mailing Address - Fax:
Practice Address - Street 1:4640 SLATER RD STE 120
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-4043
Practice Address - Country:US
Practice Address - Phone:651-882-5161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-31
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00038101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional