Provider Demographics
NPI:1205379914
Name:RUDOLPH, CONTESSA
Entity Type:Individual
Prefix:
First Name:CONTESSA
Middle Name:
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 1:882 OAKMAN BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-3710
Mailing Address - Country:US
Mailing Address - Phone:313-203-4083
Mailing Address - Fax:
Practice Address - Street 1:882 OAKMAN BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-3710
Practice Address - Country:US
Practice Address - Phone:313-203-4083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator