Provider Demographics
NPI:1396868063
Name:RUDY, SHARON NELL (LPC)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:NELL
Last Name:RUDY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 MCCORMICK DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-1641
Mailing Address - Country:US
Mailing Address - Phone:248-225-6297
Mailing Address - Fax:
Practice Address - Street 1:1080 KIRTS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4881
Practice Address - Country:US
Practice Address - Phone:248-225-6297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007089101YP2500X
MI4101006259106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist