Provider Demographics
NPI:1225186331
Name:RUDDER, EDWARD MITCHELL (MA)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:MITCHELL
Last Name:RUDDER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 TINA DR
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:NY
Mailing Address - Zip Code:12525-5412
Mailing Address - Country:US
Mailing Address - Phone:845-255-0436
Mailing Address - Fax:
Practice Address - Street 1:11 TINA DR
Practice Address - Street 2:
Practice Address - City:GARDINER
Practice Address - State:NY
Practice Address - Zip Code:12525-5412
Practice Address - Country:US
Practice Address - Phone:845-255-0436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002712101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health