Provider Demographics
NPI:1578732632
Name:MAXINE A RUDDOCK PHD P A
Entity Type:Organization
Organization Name:MAXINE A RUDDOCK PHD P A
Other - Org Name:COMPREHENSIVE PSYCHOLOGICAL & ASSESSMENT SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MAXINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUDDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:352-508-5399
Mailing Address - Street 1:2511 DORA AVE
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4977
Mailing Address - Country:US
Mailing Address - Phone:352-508-5399
Mailing Address - Fax:917-677-7121
Practice Address - Street 1:2511 DORA AVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4977
Practice Address - Country:US
Practice Address - Phone:352-508-5399
Practice Address - Fax:917-677-7121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7658251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004100303Medicaid
FL004100300Medicaid
FL008487400Medicaid
FL008487400Medicaid