Provider Demographics
NPI:1376661512
Name:RUDESTAM, KJELL ERIK (PHD)
Entity type:Individual
Prefix:DR
First Name:KJELL
Middle Name:ERIK
Last Name:RUDESTAM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3924 FOOTHILL RD
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93110-1208
Mailing Address - Country:US
Mailing Address - Phone:805-569-2540
Mailing Address - Fax:805-687-4590
Practice Address - Street 1:2020 ALAMEDA PADRE SERRA
Practice Address - Street 2:SUITE217
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93103-1756
Practice Address - Country:US
Practice Address - Phone:805-569-2540
Practice Address - Fax:805-687-4590
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 5930103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical