Provider Demographics
NPI:1912637778
Name:RUDKIN, PAMELA MARIE (MA, PPS)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:MARIE
Last Name:RUDKIN
Suffix:
Gender:F
Credentials:MA, PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6731 E BOSCANA CT
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-6406
Mailing Address - Country:US
Mailing Address - Phone:949-290-1752
Mailing Address - Fax:
Practice Address - Street 1:6731 E BOSCANA CT
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-6406
Practice Address - Country:US
Practice Address - Phone:949-290-1752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool