MEDICARE: RUDDY TAYLOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1372	AK

General Provider Information

NPI Number	:	1114399623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUDDY TAYLOR

Provider Business Mailing Address
First Line	:	PO BOX 200688
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99520-0688
Country	:	US
Telephone Number	:	907-223-3632
Fax Number	:

Provider Business Practice Location Address
First Line	:	5391 CARIBOU AVE
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-2560
Country	:	US
Telephone Number	:	907-223-3632
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2015
Last Update Date	:	10/22/2015

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