Provider Demographics
NPI:1043671662
Name:RUDIN, MICHAEL IRVIN
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:IRVIN
Last Name:RUDIN
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 1:1328 WESTWOOD BLVD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4941
Mailing Address - Country:US
Mailing Address - Phone:310-259-5606
Mailing Address - Fax:
Practice Address - Street 1:1328 WESTWOOD BLVD
Practice Address - Street 2:SUITE 8
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4941
Practice Address - Country:US
Practice Address - Phone:310-259-5606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 53187106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist