Provider Demographics
NPI:1801925219
Name:RUDDOCK, AMBER CHRISTINE (PHD)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:CHRISTINE
Last Name:RUDDOCK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6648 BUTTONWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91377-1327
Mailing Address - Country:US
Mailing Address - Phone:818-293-7920
Mailing Address - Fax:818-865-1232
Practice Address - Street 1:346 KANAN RD
Practice Address - Street 2:STE 203
Practice Address - City:OAK PARK
Practice Address - State:CA
Practice Address - Zip Code:91377-1100
Practice Address - Country:US
Practice Address - Phone:818-293-7920
Practice Address - Fax:818-865-1232
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22609103T00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator