Provider Demographics
NPI:1467576181
Name:RUDIGER, KYLE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KYLE
Middle Name:
Last Name:RUDIGER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2316 73RD AVENUE CT
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-8684
Mailing Address - Country:US
Mailing Address - Phone:970-397-0627
Mailing Address - Fax:
Practice Address - Street 1:2316 73RD AVENUE CT
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-8684
Practice Address - Country:US
Practice Address - Phone:970-397-0627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0353426235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12255076Medicaid