Provider Demographics
NPI:1780492777
Name:RUDDELL, COLLIN WOLFE
Entity type:Individual
Prefix:MR
First Name:COLLIN
Middle Name:WOLFE
Last Name:RUDDELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 ASPEN LN
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-1454
Mailing Address - Country:US
Mailing Address - Phone:419-503-7102
Mailing Address - Fax:
Practice Address - Street 1:8044 MONTGOMERY RD STE 120
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-2919
Practice Address - Country:US
Practice Address - Phone:513-607-5128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-21
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.005608175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist