Provider Demographics
NPI:1568779916
Name:RUDDER, DESIREE FORREST (LMT,CADC I)
Entity Type:Individual
Prefix:MS
First Name:DESIREE
Middle Name:FORREST
Last Name:RUDDER
Suffix:
Gender:F
Credentials:LMT,CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 SAGINAW ST S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4122
Mailing Address - Country:US
Mailing Address - Phone:503-503-7868
Mailing Address - Fax:
Practice Address - Street 1:2111 FRONT ST NE STE 3-101
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0038
Practice Address - Country:US
Practice Address - Phone:503-508-7868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14427172M00000X
OR18-08-32101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172M00000XOther Service ProvidersMechanotherapist