Provider Demographics
NPI:1174180848
Name:RUDISH, MICHELLE ANN (LLBSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:RUDISH
Suffix:
Gender:F
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 N GROESBECK HWY
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-1562
Mailing Address - Country:US
Mailing Address - Phone:586-627-0024
Mailing Address - Fax:
Practice Address - Street 1:175 N GROESBECK HWY
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-1562
Practice Address - Country:US
Practice Address - Phone:586-627-0024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2023-12-15
Deactivation Date:2023-11-28
Deactivation Code:
Reactivation Date:2023-12-11
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker