Provider Demographics
NPI:1225621246
Name:RUDD, DARIUS BJ
Entity Type:Individual
Prefix:
First Name:DARIUS
Middle Name:BJ
Last Name:RUDD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 N 78TH CT
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707-1013
Mailing Address - Country:US
Mailing Address - Phone:618-401-0668
Mailing Address - Fax:
Practice Address - Street 1:3111 N 78TH CT
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:IL
Practice Address - Zip Code:60707-1013
Practice Address - Country:US
Practice Address - Phone:618-401-0668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-20
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.016482101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional