Healthcare Provider Details

I. General information

NPI: 1760937692
Provider Name (Legal Business Name): MISS KRISTEN SUZANNE RUDOLF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2016
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W 8TH AVE STE 300
EUGENE OR
97401-2997
US

IV. Provider business mailing address

PO BOX 1530
WALDPORT OR
97394-1530
US

V. Phone/Fax

Practice location:
  • Phone: 541-243-7544
  • Fax:
Mailing address:
  • Phone: 650-468-0003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC7820
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: