Provider Demographics
NPI:1114928181
Name:RUDISILL, TERESA L
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:L
Last Name:RUDISILL
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 1:2817 TORREY PNES
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-8614
Mailing Address - Country:US
Mailing Address - Phone:937-266-6914
Mailing Address - Fax:937-426-1882
Practice Address - Street 1:1020 WOODMAN DR
Practice Address - Street 2:SUITE300
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-1446
Practice Address - Country:US
Practice Address - Phone:937-266-6914
Practice Address - Fax:937-426-1882
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2013-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4904103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH066040Medicare PIN