Provider Demographics
NPI:1255683546
Name:TRUDEAU, TINA (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:
Last Name:TRUDEAU
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 PARDEE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14609-2810
Mailing Address - Country:US
Mailing Address - Phone:585-339-1375
Mailing Address - Fax:585-339-1379
Practice Address - Street 1:600 PARDEE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609-2810
Practice Address - Country:US
Practice Address - Phone:585-339-1375
Practice Address - Fax:585-339-1379
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY720471271041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY100295Medicaid