Provider Demographics
NPI:1417013723
Name:RUDOLPH, ANN M (L-CSW-R)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:L-CSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2250
Mailing Address - Country:US
Mailing Address - Phone:631-331-4458
Mailing Address - Fax:
Practice Address - Street 1:1000 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2250
Practice Address - Country:US
Practice Address - Phone:631-331-4458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR037202-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5169741OtherAETNA
NYP1626359OtherOXFORD
NY071480OtherVALUE OPTIONS
NY7404242OtherGHI
NY13690OtherVYTRA
NY5169741OtherAETNA