Provider Demographics
NPI:1821413444
Name:RUDD, ELISA A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ELISA
Middle Name:A
Last Name:RUDD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 NW 116TH AVE APT 402
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-6099
Mailing Address - Country:US
Mailing Address - Phone:503-853-1196
Mailing Address - Fax:
Practice Address - Street 1:2400 SW VERMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-1940
Practice Address - Country:US
Practice Address - Phone:503-853-1196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR185947OtherMEDICARE PTAN