Provider Demographics
NPI:1023738507
Name:RUDDER, DESTINY DOMINIQUE
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:DOMINIQUE
Last Name:RUDDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DESTINY
Other - Middle Name:DOMINIQUE
Other - Last Name:ATKINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT/DPT
Mailing Address - Street 1:119 W 57TH ST STE 600
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-2305
Mailing Address - Country:US
Mailing Address - Phone:212-974-7252
Mailing Address - Fax:212-974-7252
Practice Address - Street 1:119 W 57TH ST STE 600
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-2305
Practice Address - Country:US
Practice Address - Phone:212-974-7252
Practice Address - Fax:212-974-7252
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04938401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist