Provider Demographics
NPI:1427320886
Name:RUDDELL, MANDY PHILLIPS
Entity type:Individual
Prefix:DR
First Name:MANDY
Middle Name:PHILLIPS
Last Name:RUDDELL
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 1:5150 STILESBORO RD NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-7744
Mailing Address - Country:US
Mailing Address - Phone:404-680-3032
Mailing Address - Fax:
Practice Address - Street 1:5150 STILESBORO RD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-7744
Practice Address - Country:US
Practice Address - Phone:404-680-3032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003837101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional