Healthcare Provider Details

I. General information

NPI: 1962000224
Provider Name (Legal Business Name): PAUL WESLEY RHUDY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WHIG ST
TRUMANSBURG NY
14886-9152
US

IV. Provider business mailing address

2 EAGLESHEAD RD
ITHACA NY
14850-9659
US

V. Phone/Fax

Practice location:
  • Phone: 607-387-7551
  • Fax:
Mailing address:
  • Phone: 607-592-6607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number074397-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: