Provider Demographics
NPI:1871594853
Name:RUDISILL, JOHN R
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:RUDISILL
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 1:1020 WOODMAN DR
Mailing Address - Street 2:SUITE 225
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45432-1446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1020 WOODMAN DR
Practice Address - Street 2:SUITE 225
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-1446
Practice Address - Country:US
Practice Address - Phone:937-254-9210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2565103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical