Provider Demographics
NPI:1154320489
Name:RUDOLPH, TERRY LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:LEE
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25779 KELLY ROAD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4973
Mailing Address - Country:US
Mailing Address - Phone:586-774-7987
Mailing Address - Fax:586-774-7263
Practice Address - Street 1:25779 KELLY ROAD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4973
Practice Address - Country:US
Practice Address - Phone:586-774-7987
Practice Address - Fax:586-774-7263
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003357103T00000X
MI003357103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI68-0-E0-4564-0OtherBLUE CROSS/BLUE SHIELD
0M-3837O0Medicare UPIN
MI68-0-E0-4564-0OtherBLUE CROSS/BLUE SHIELD
79915Medicare UPIN