Provider Demographics
NPI:1669169322
Name:RUDDER, LACY (PLDAC)
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:RUDDER
Suffix:
Gender:F
Credentials:PLDAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8502 MORMON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68152-1929
Mailing Address - Country:US
Mailing Address - Phone:402-991-8518
Mailing Address - Fax:402-455-7050
Practice Address - Street 1:8502 MORMON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68152-1929
Practice Address - Country:US
Practice Address - Phone:402-991-8518
Practice Address - Fax:402-455-7050
Is Sole Proprietor?:No
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-2056101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)