Provider Demographics
NPI:1922209493
Name:RUDDY, TOM RICHARD
Entity Type:Individual
Prefix:MR
First Name:TOM
Middle Name:RICHARD
Last Name:RUDDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 S EL PARADISO UNIT 10
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-7477
Mailing Address - Country:US
Mailing Address - Phone:480-313-2468
Mailing Address - Fax:
Practice Address - Street 1:2524 S EL PARADISO UNIT 10
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-7477
Practice Address - Country:US
Practice Address - Phone:480-313-2468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist