Provider Demographics
NPI:1003863382
Name:RUDOLPH, LIZA RAQUEL (PHD)
Entity Type:Individual
Prefix:MRS
First Name:LIZA
Middle Name:RAQUEL
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MRS
Other - First Name:LIZA
Other - Middle Name:RAQUEL
Other - Last Name:SIMENTAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 3884
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47996-3884
Mailing Address - Country:US
Mailing Address - Phone:765-532-9084
Mailing Address - Fax:765-447-9659
Practice Address - Street 1:255 E SUNSET LN
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-2456
Practice Address - Country:US
Practice Address - Phone:765-532-9084
Practice Address - Fax:765-447-9659
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN200251030103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000378693OtherBLUE CROSS/BLUE SHIELD
IN251277OtherVALUE OPTIONS
IN200251030BMedicaid
IN284435000OtherMAGELLAN
IN284435000OtherMAGELLAN
INS89659Medicare UPIN