Provider Demographics
NPI:1912044124
Name:RUDERMAN, LISA AMY (MA MFT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:AMY
Last Name:RUDERMAN
Suffix:
Gender:F
Credentials:MA MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10646 BRIARLAKE WOODS DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-4832
Mailing Address - Country:US
Mailing Address - Phone:858-481-7477
Mailing Address - Fax:858-481-7456
Practice Address - Street 1:9850 GENESEE AVE
Practice Address - Street 2:425
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1224
Practice Address - Country:US
Practice Address - Phone:858-452-8467
Practice Address - Fax:858-452-8547
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37853101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health