Provider Demographics
NPI:1780079053
Name:TRUDELL, DEBORAH (MA)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:TRUDELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12764 STATE ROAD TT
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4345
Mailing Address - Country:US
Mailing Address - Phone:636-232-8328
Mailing Address - Fax:
Practice Address - Street 1:508 N TRUMAN BLVD STE J
Practice Address - Street 2:
Practice Address - City:CRYSTAL CITY
Practice Address - State:MO
Practice Address - Zip Code:63019-1344
Practice Address - Country:US
Practice Address - Phone:636-232-8328
Practice Address - Fax:888-388-2740
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTPMC2079101YM0800X
MO2012040482101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health