Provider Demographics
NPI:1376678409
Name:RUDISILL, AMY J (MHS)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:RUDISILL
Suffix:
Gender:F
Credentials:MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 TILLMAN STREET
Mailing Address - Street 2:SUITE 105 B
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18104-4354
Mailing Address - Country:US
Mailing Address - Phone:484-221-9136
Mailing Address - Fax:
Practice Address - Street 1:865 EAST
Practice Address - Street 2:4TH STREET
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015
Practice Address - Country:US
Practice Address - Phone:610-865-8177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
PAPC004900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health