MEDICARE: ALYSSA RUDMAN LPC

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	2019043833	MO

General Provider Information

NPI Number	:	1740961796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSSA RUDMAN LPC

Provider Business Mailing Address
First Line	:	7337 HAWTHORNE AVE
Second Line	:
City	:	UNIVERSITY CITY
State	:	MO
Zip	:	63130-1416
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 EXECUTIVE PARKWAY DR
Second Line	:
City	:	CREVE COEUR
State	:	MO
Zip	:	63141-6325
Country	:	US
Telephone Number	:	785-766-5492
Fax Number	:

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

Provider Enumeration Date	:	07/31/2023
Last Update Date	:	07/31/2023

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