Provider Demographics
NPI:1366757098
Name:RUDBERG, MARY R (LPC, CRC, CACD, MS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:RUDBERG
Suffix:
Gender:F
Credentials:LPC, CRC, CACD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 BLIND LN
Mailing Address - Street 2:
Mailing Address - City:BELLE VERNON
Mailing Address - State:PA
Mailing Address - Zip Code:15012-1280
Mailing Address - Country:US
Mailing Address - Phone:724-243-3161
Mailing Address - Fax:724-243-3161
Practice Address - Street 1:524 BLIND LN
Practice Address - Street 2:
Practice Address - City:BELLE VERNON
Practice Address - State:PA
Practice Address - Zip Code:15012-1280
Practice Address - Country:US
Practice Address - Phone:724-243-3161
Practice Address - Fax:724-243-3161
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004450101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health