Provider Demographics
NPI:1205014461
Name:RUDDOCK, MAXINE A (PHD)
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:A
Last Name:RUDDOCK
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 1:2511 DORA AVE
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4977
Mailing Address - Country:US
Mailing Address - Phone:352-508-5399
Mailing Address - Fax:917-677-7121
Practice Address - Street 1:2511 DORA AVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4977
Practice Address - Country:US
Practice Address - Phone:352-508-5399
Practice Address - Fax:917-677-7121
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-08
Last Update Date:2015-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7658103TC0700X, 101YM0800X, 101YA0400X, 101YP2500X, 1041C0700X, 103TP2701X, 103T00000X, 103TA0400X, 103TA0700X, 103TC2200X, 103TB0200X, 103TC1900X, 103TM1800X, 101Y00000X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008648900Medicaid
FL004105100Medicaid
FLAJ642XMedicare UPIN
FL008648900Medicaid