=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184581837
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. ELLIS DAVID RUDAN JR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2026
-----------------------------------------------------
Last Update Date | 01/06/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 LINCOLNWAY E
-----------------------------------------------------
City | MISHAWAKA
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46544-2016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-314-5987
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 318 S ELKHART AVE APT 344
-----------------------------------------------------
City | ELKHART
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46516-3584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------