Provider Demographics
NPI:1538449327
Name:RUDKIN, AMY MICHELLE (LCSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MICHELLE
Last Name:RUDKIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5853
Mailing Address - Country:US
Mailing Address - Phone:530-273-2233
Mailing Address - Fax:
Practice Address - Street 1:900 E MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5853
Practice Address - Country:US
Practice Address - Phone:530-273-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA717031041C0700X
CA35122101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health