Provider Demographics
NPI:1902011299
Name:RUDY, LESLIE A (PHD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:RUDY
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:CHILDREN'S HOSPITAL GUIDANCE CENTER
Mailing Address - Street 2:899 E. BROAD ST 3RD FLOOR
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205
Mailing Address - Country:US
Mailing Address - Phone:614-355-8000
Mailing Address - Fax:614-355-8000
Practice Address - Street 1:CHILDREN'S HOSPITAL GUIDANCE CENTER
Practice Address - Street 2:655 E. LIVINGSTON AVE
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205
Practice Address - Country:US
Practice Address - Phone:614-355-8000
Practice Address - Fax:614-355-8018
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5272103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH08258Medicare UPIN