Healthcare Provider Details

I. General information

NPI: 1376637538
Provider Name (Legal Business Name): RHETT J PUDER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BEE ST
CHARLESTON SC
29401-5703
US

IV. Provider business mailing address

109 BEE ST
CHARLESTON SC
29401-5703
US

V. Phone/Fax

Practice location:
  • Phone: 843-577-5011
  • Fax:
Mailing address:
  • Phone: 843-577-5011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1413
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3078
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: