MEDICARE: VANDA RUDEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist		NY

General Provider Information

NPI Number	:	1073158689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANDA RUDEZ

Provider Business Mailing Address
First Line	:	PO BOX 402
Second Line	:
City	:	JEFFERSON VALLEY
State	:	NY
Zip	:	10535-0402
Country	:	US
Telephone Number	:	321-424-0654
Fax Number	:

Provider Business Practice Location Address
First Line	:	3151 STONY ST
Second Line	:
City	:	MOHEGAN LAKE
State	:	NY
Zip	:	10547-1913
Country	:	US
Telephone Number	:	914-885-0110
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2019
Last Update Date	:	11/07/2019

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Directions to “ VANDA RUDEZ ” Practice Location

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