Provider Demographics
NPI:1285250126
Name:RUDD, CAROL JEAN (LMT)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:JEAN
Last Name:RUDD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 PLEASANT ST STE 1E
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-2503
Mailing Address - Country:US
Mailing Address - Phone:715-456-1936
Mailing Address - Fax:
Practice Address - Street 1:2711 PLEASANT ST STE 1E
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-2503
Practice Address - Country:US
Practice Address - Phone:715-456-1936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2129-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty