Provider Demographics
NPI:1134889934
Name:RUDER, MICHELLE T (LPC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:T
Last Name:RUDER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 COBBLESTONE BLVD S
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-7075
Mailing Address - Country:US
Mailing Address - Phone:662-892-2885
Mailing Address - Fax:662-892-2889
Practice Address - Street 1:3495 COBBLESTONE BLVD S
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-7075
Practice Address - Country:US
Practice Address - Phone:662-892-2885
Practice Address - Fax:662-892-2889
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-21
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2999101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty