Provider Demographics
NPI:1962470278
Name:RUDA, LORI JEAN (OTR)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:JEAN
Last Name:RUDA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8662 ELK AVE
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-2805
Mailing Address - Country:US
Mailing Address - Phone:763-295-4987
Mailing Address - Fax:
Practice Address - Street 1:5700 BOTTINEAU BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429-3183
Practice Address - Country:US
Practice Address - Phone:763-535-7607
Practice Address - Fax:763-535-7649
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102908225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist