Healthcare Provider Details

I. General information

NPI: 1033544671
Provider Name (Legal Business Name): MISS BONNIE J RUDDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2013
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 CUMMINGS CTR STE 226T
BEVERLY MA
01915-6175
US

IV. Provider business mailing address

5200 S MACADAM AVE STE 580
PORTLAND OR
97239-3837
US

V. Phone/Fax

Practice location:
  • Phone: 978-921-1190
  • Fax:
Mailing address:
  • Phone: 978-729-3605
  • Fax: 503-231-8153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: