Healthcare Provider Details

I. General information

NPI: 1346855772
Provider Name (Legal Business Name): AARON I RUDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2020
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 CIVIC CENTER DR STE 100
SAN RAFAEL CA
94903-4151
US

IV. Provider business mailing address

55 CORTE REAL APT 20
GREENBRAE CA
94904-2145
US

V. Phone/Fax

Practice location:
  • Phone: 628-877-0040
  • Fax:
Mailing address:
  • Phone: 510-290-2593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-66738
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-31955
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: