Provider Demographics
NPI:1255680344
Name:RUDY NYDEGGER PHD, ABPP, PLLC
Entity Type:Organization
Organization Name:RUDY NYDEGGER PHD, ABPP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUDY
Authorized Official - Middle Name:V
Authorized Official - Last Name:NYDEGGER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:518-377-4398
Mailing Address - Street 1:2317 BALLTOWN RD.
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12309
Mailing Address - Country:US
Mailing Address - Phone:518-377-4398
Mailing Address - Fax:518-384-3475
Practice Address - Street 1:2317 BALLTOWN RD.
Practice Address - Street 2:SUITE 203
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12309
Practice Address - Country:US
Practice Address - Phone:518-377-4398
Practice Address - Fax:518-384-3475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5721103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03537919Medicaid
NYJ100090663Medicare UPIN