Provider Demographics
NPI:1356810766
Name:RUDZIK, GEORGINA HELENE
Entity type:Individual
Prefix:
First Name:GEORGINA
Middle Name:HELENE
Last Name:RUDZIK
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 1:1211 W OCOTILLO ST
Mailing Address - Street 2:
Mailing Address - City:COOLIDGE
Mailing Address - State:AZ
Mailing Address - Zip Code:85128-9152
Mailing Address - Country:US
Mailing Address - Phone:541-740-8642
Mailing Address - Fax:602-455-4626
Practice Address - Street 1:1211 W OCOTILLO ST
Practice Address - Street 2:
Practice Address - City:COOLIDGE
Practice Address - State:AZ
Practice Address - Zip Code:85128-9152
Practice Address - Country:US
Practice Address - Phone:541-740-8642
Practice Address - Fax:602-455-4624
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9229105385HR2055X, 253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child