Provider Demographics
NPI:1942742101
Name:RUDER, LYNN
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:RUDER
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 1:22 STARLIT DR
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3515
Mailing Address - Country:US
Mailing Address - Phone:631-278-9250
Mailing Address - Fax:
Practice Address - Street 1:5036 JERICHO TPKE STE 203
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2812
Practice Address - Country:US
Practice Address - Phone:631-278-9259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-04
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
NY72 0981591041C0700X
NY0907701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical