Provider Demographics
NPI:1609962976
Name:RUDIN, STEPHEN GERALD (EDD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:GERALD
Last Name:RUDIN
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 NW 18TH ST
Mailing Address - Street 2:NO. 204
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-6857
Mailing Address - Country:US
Mailing Address - Phone:954-970-3205
Mailing Address - Fax:954-957-7505
Practice Address - Street 1:1342 BELMONT ST
Practice Address - Street 2:SUITE 204
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4436
Practice Address - Country:US
Practice Address - Phone:508-427-6911
Practice Address - Fax:508-588-4639
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPY-635-PR103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA290594OtherMENTAL HEALTH NETWORK MHN
MAW01468OtherBLUE SHIELD OF MASSACHUSE
MA42279OtherHARVARD PILGRIM HEALTH CA
MA732869OtherTUFTS HEALTH PLANS
MA732869OtherTUFTS HEALTH PLANS