Healthcare Provider Details

I. General information

NPI: 1225609035
Provider Name (Legal Business Name): MRS. SUSAN KAY KUDER II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2021
Last Update Date: 07/03/2021
Certification Date: 07/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11037 ERICKSON WAY SPC 1811037
REDDING CA
96003-2934
US

IV. Provider business mailing address

11037 ERICKSON WAY SPC 1811037
REDDING CA
96003-2934
US

V. Phone/Fax

Practice location:
  • Phone: 856-431-4629
  • Fax:
Mailing address:
  • Phone: 856-431-4629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101200000X
TaxonomyDrama Therapist
License NumberC3417740
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: