Healthcare Provider Details

I. General information

NPI: 1114928181
Provider Name (Legal Business Name): TERESA L RUDISILL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 01/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 WOODMAN DR SUITE300
DAYTON OH
45432-1446
US

IV. Provider business mailing address

2817 TORREY PNES
BEAVERCREEK OH
45431-8614
US

V. Phone/Fax

Practice location:
  • Phone: 937-266-6914
  • Fax: 937-426-1882
Mailing address:
  • Phone: 937-266-6914
  • Fax: 937-426-1882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4904
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: