Provider Demographics
NPI:1265577282
Name:RUDNICK, SANDRA SIMMONS (PHD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:SIMMONS
Last Name:RUDNICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15760 VENTURA BLVD
Mailing Address - Street 2:SUITE 1929
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-3000
Mailing Address - Country:US
Mailing Address - Phone:818-783-0790
Mailing Address - Fax:818-906-3569
Practice Address - Street 1:15760 VENTURA BLVD
Practice Address - Street 2:SUITE 1929
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-3000
Practice Address - Country:US
Practice Address - Phone:818-783-0790
Practice Address - Fax:818-906-3569
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10197103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP10197Medicare ID - Type Unspecified