MEDICARE: NICHOLAS RUDGEAR

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	101YM0800X	Mental Health Counselor	LPC-18103	AZ

General Provider Information

NPI Number	:	1407329048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS RUDGEAR

Provider Business Mailing Address
First Line	:	1440 E MISSOURI AVE STE C160
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-2458
Country	:	US
Telephone Number	:	602-878-8142
Fax Number	:

Provider Business Practice Location Address
First Line	:	1440 E MISSOURI AVE STE C160
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-2458
Country	:	US
Telephone Number	:	602-878-8142
Fax Number	:

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

Provider Enumeration Date	:	01/07/2019
Last Update Date	:	06/13/2024

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Directions to “ NICHOLAS RUDGEAR ” Practice Location

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