Provider Demographics
NPI:1366143224
Name:RUDKIN, TALIA
Entity type:Individual
Prefix:
First Name:TALIA
Middle Name:
Last Name:RUDKIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2985 N 935 E STE 7
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040-7318
Mailing Address - Country:US
Mailing Address - Phone:801-771-0273
Mailing Address - Fax:801-771-0221
Practice Address - Street 1:404 E 4500 S STE A34
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2710
Practice Address - Country:US
Practice Address - Phone:901-771-0273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-23-263215103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty