MEDICARE: DR. KJELL ERIK RUDESTAM PH.D.

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	103TC0700X	Clinical Psychologist	PSY 5930	CA

General Provider Information

NPI Number	:	1376661512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KJELL ERIK RUDESTAM PH.D.

Provider Business Mailing Address
First Line	:	3924 FOOTHILL RD
Second Line	:
City	:	SANTA BARBARA
State	:	CA
Zip	:	93110-1208
Country	:	US
Telephone Number	:	805-569-2540
Fax Number	:	805-687-4590

Provider Business Practice Location Address
First Line	:	2020 ALAMEDA PADRE SERRA
Second Line	:	SUITE217
City	:	SANTA BARBARA
State	:	CA
Zip	:	93103-1756
Country	:	US
Telephone Number	:	805-569-2540
Fax Number	:	805-687-4590

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

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	07/08/2007

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