Provider Demographics
NPI:1770455206
Name:RUDNICK, CARLY PAIGE (MS, LCGC)
Entity type:Individual
Prefix:MISS
First Name:CARLY
Middle Name:PAIGE
Last Name:RUDNICK
Suffix:
Gender:F
Credentials:MS, LCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 EL CAMINO DR APT B
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5555
Mailing Address - Country:US
Mailing Address - Phone:678-640-5403
Mailing Address - Fax:
Practice Address - Street 1:1022 EL CAMINO DR APT B
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5555
Practice Address - Country:US
Practice Address - Phone:678-640-5403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGC002008170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS