Provider Demographics
NPI:1346784147
Name:LUDOLPH, SHELLY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:
Last Name:LUDOLPH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5108 KUHINA PL
Mailing Address - Street 2:
Mailing Address - City:PRINCEVILLE
Mailing Address - State:HI
Mailing Address - Zip Code:96722-5116
Mailing Address - Country:US
Mailing Address - Phone:808-652-0466
Mailing Address - Fax:
Practice Address - Street 1:3-3122 KUHIO HWY STE A15
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-1157
Practice Address - Country:US
Practice Address - Phone:808-246-9102
Practice Address - Fax:808-246-8609
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-13
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1828103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical