Provider Demographics
NPI:1245768803
Name:RUDD, ALEXIS VICTORIA
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:VICTORIA
Last Name:RUDD
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 1:3522 E DEERFIELD RD APT U29
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-5545
Mailing Address - Country:US
Mailing Address - Phone:260-446-9485
Mailing Address - Fax:
Practice Address - Street 1:504 PINE AVE
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1723
Practice Address - Country:US
Practice Address - Phone:989-285-9122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-26
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician