Provider Demographics
NPI:1275575680
Name:RUDOLPH, SUZANNE MARIE (EDD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:MARIE
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 W 11TH STREET RD
Mailing Address - Street 2:SUITE 23
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-5464
Mailing Address - Country:US
Mailing Address - Phone:970-203-0643
Mailing Address - Fax:970-351-7165
Practice Address - Street 1:2619 W 11TH STREET RD
Practice Address - Street 2:SUITE 23
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-5464
Practice Address - Country:US
Practice Address - Phone:970-203-0643
Practice Address - Fax:970-351-7165
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1815103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO62856Medicare PIN