Provider Demographics
NPI:1659990893
Name:RUDDEROW, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:RUDDEROW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 E RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-4812
Mailing Address - Country:US
Mailing Address - Phone:856-430-4691
Mailing Address - Fax:
Practice Address - Street 1:2640 E RIVIERA DR
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85249-4812
Practice Address - Country:US
Practice Address - Phone:856-430-4691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH-000552103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst