Provider Demographics
NPI:1699834960
Name:RUDERMAN, ELLEN G (PHD PSYD LCSW)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:G
Last Name:RUDERMAN
Suffix:
Gender:F
Credentials:PHD PSYD LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16055 VENTURA BLVD STE 1110
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436
Mailing Address - Country:US
Mailing Address - Phone:818-784-7090
Mailing Address - Fax:818-981-3477
Practice Address - Street 1:16055 VENTURA BLVD STE 1110
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436
Practice Address - Country:US
Practice Address - Phone:818-784-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACERTIFICATE103TP0814X
CA0002411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALA #000241OtherSTATE OF CALIFORNIA