Healthcare Provider Details

I. General information

NPI: 1134889934
Provider Name (Legal Business Name): MICHELLE T RUDER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2021
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6952 DOGWOOD MNR N STE 103
OLIVE BRANCH MS
38654-2091
US

IV. Provider business mailing address

6952 DOGWOOD MNR N STE 103
OLIVE BRANCH MS
38654-2091
US

V. Phone/Fax

Practice location:
  • Phone: 662-874-6921
  • Fax: 662-932-2921
Mailing address:
  • Phone: 662-801-6696
  • Fax: 662-932-2921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2999
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: