Provider Demographics
NPI:1457584138
Name:RUDERMAN, PETER MITCHELL (MSW)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:MITCHELL
Last Name:RUDERMAN
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8820 LADUE ROAD
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124
Mailing Address - Country:US
Mailing Address - Phone:314-754-3253
Mailing Address - Fax:
Practice Address - Street 1:8820 LADUE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63124-2079
Practice Address - Country:US
Practice Address - Phone:314-754-3253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000742102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst