Provider Demographics
NPI:1811412356
Name:RUDNITSKY, LISA S
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:S
Last Name:RUDNITSKY
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 1:445 NEPTUNE AVE APT 12D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-4558
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:445 NEPTUNE AVENUE, 12D
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224
Practice Address - Country:US
Practice Address - Phone:917-502-9994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-05
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program