Provider Demographics
NPI:1396214177
Name:JOHNSRUDE, STEVEN LEE
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:LEE
Last Name:JOHNSRUDE
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 1:2546 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-2643
Mailing Address - Country:US
Mailing Address - Phone:408-771-4589
Mailing Address - Fax:
Practice Address - Street 1:1001 SNEATH LN STE 200
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-2349
Practice Address - Country:US
Practice Address - Phone:408-771-4589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician