Provider Demographics
NPI:1154596195
Name:RUDDELL, JOHNETTE B (SLP)
Entity type:Individual
Prefix:
First Name:JOHNETTE
Middle Name:B
Last Name:RUDDELL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7726 US HWY 165
Mailing Address - Street 2:HAVEN REHABILITATION CENTER
Mailing Address - City:COLUMBIA
Mailing Address - State:LA
Mailing Address - Zip Code:71418
Mailing Address - Country:US
Mailing Address - Phone:318-649-9826
Mailing Address - Fax:318-649-9827
Practice Address - Street 1:7726 US HWY 165
Practice Address - Street 2:HAVEN REHABILITATION CENTER
Practice Address - City:COLUMBIA
Practice Address - State:LA
Practice Address - Zip Code:71418
Practice Address - Country:US
Practice Address - Phone:318-649-9826
Practice Address - Fax:318-649-9827
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3699235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA$$$$$$$$$AOtherBLUE CROSS/BLUE SHIELD