Provider Demographics
NPI:1194379768
Name:RUDOLPH, JOSHUA LEE (MHA)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:LEE
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-0713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1051 N 16TH ST STE B
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-8511
Practice Address - Country:US
Practice Address - Phone:270-753-6622
Practice Address - Fax:270-753-9669
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker