Provider Demographics
NPI:1336220326
Name:RUDIKOFF, ELLEN (PHD, PSYD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:RUDIKOFF
Suffix:
Gender:F
Credentials:PHD, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 LITTLEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON CENTRE
Mailing Address - State:MA
Mailing Address - Zip Code:02459-3009
Mailing Address - Country:US
Mailing Address - Phone:617-244-0109
Mailing Address - Fax:
Practice Address - Street 1:35 LITTLEFIELD RD
Practice Address - Street 2:
Practice Address - City:NEWTON CENTRE
Practice Address - State:MA
Practice Address - Zip Code:02459-3009
Practice Address - Country:US
Practice Address - Phone:617-244-0109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4760103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RUW50562Medicare PIN