Provider Demographics
NPI:1417505538
Name:RUDY, JOHN PIERRE (PHD, HSPP)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PIERRE
Last Name:RUDY
Suffix:
Gender:M
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3464 CINNAMON TRCE
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-3981
Mailing Address - Country:US
Mailing Address - Phone:765-860-9059
Mailing Address - Fax:
Practice Address - Street 1:3464 CINNAMON TRCE
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-3981
Practice Address - Country:US
Practice Address - Phone:765-860-9059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-02
Last Update Date:2019-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010449A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical