Provider Demographics
NPI:1770649402
Name:IREDALE, TRUDY A (PHD)
Entity Type:Individual
Prefix:DR
First Name:TRUDY
Middle Name:A
Last Name:IREDALE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 SE 170TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-3474
Mailing Address - Country:US
Mailing Address - Phone:360-991-0134
Mailing Address - Fax:360-991-0154
Practice Address - Street 1:1804 SE 170TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-3474
Practice Address - Country:US
Practice Address - Phone:360-991-0134
Practice Address - Fax:360-991-0154
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1597103TC0700X
WAPY00003097103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1770649402OtherNPI
1841811783OtherTYPE II NPI
OR164936Medicaid