Provider Demographics
NPI:1750913265
Name:BLEVINS-RUDD, MICAH LEIGH
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:LEIGH
Last Name:BLEVINS-RUDD
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 1:909 LEEPER DR
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-1742
Mailing Address - Country:US
Mailing Address - Phone:580-230-8088
Mailing Address - Fax:
Practice Address - Street 1:909 LEEPER DR
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-1742
Practice Address - Country:US
Practice Address - Phone:580-230-8088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33877106106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician