Provider Demographics
NPI:1164952982
Name:RUDOLPH, MAXI ALEXIS
Entity Type:Individual
Prefix:
First Name:MAXI
Middle Name:ALEXIS
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 SENTRY PKWY W STE 300
Mailing Address - Street 2:
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-2211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1777 SENTRY PKWY W STE 300
Practice Address - Street 2:
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-2211
Practice Address - Country:US
Practice Address - Phone:215-767-7096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101YP2500XOtherCOUNSELOR PROFESSIONAL