Basic Information
| Provider Information | |||||||||
| NPI: | 1366878514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUDOLPH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20800 WESTGATE PROF CENTER SUITE 200 | ||||||||
| Address2: | |||||||||
| City: | FAIRVIEW | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403334949 | ||||||||
| FaxNumber: | 4403335044 | ||||||||
| Practice Location | |||||||||
| Address1: | 20800 WESTGATE PROF CENTER | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FAIRVIEW | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403334949 | ||||||||
| FaxNumber: | 4403335044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2013 | ||||||||
| LastUpdateDate: | 09/19/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0800416 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.