Provider Demographics
NPI:1558400531
Name:RUDNICK, PEGGY REINES (LCSW, BCD)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:REINES
Last Name:RUDNICK
Suffix:
Gender:F
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:R
Other - Last Name:HALYO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, BCD
Mailing Address - Street 1:62815 SNOWCAP CT
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7665
Mailing Address - Country:US
Mailing Address - Phone:757-508-1972
Mailing Address - Fax:541-318-1249
Practice Address - Street 1:255 SW BLUFF DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3220
Practice Address - Country:US
Practice Address - Phone:757-508-1972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040010801041C0700X
OR136391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8952710Medicaid
VA800002922Medicare ID - Type Unspecified