Provider Demographics
NPI:1467690883
Name:RUDOLPH, AMY (PT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21117 E 50TH TERRACE DR S
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64015-2257
Mailing Address - Country:US
Mailing Address - Phone:816-229-3902
Mailing Address - Fax:
Practice Address - Street 1:10000 W 75TH ST
Practice Address - Street 2:SUITE 250
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204-2209
Practice Address - Country:US
Practice Address - Phone:913-894-1910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105449225100000X
KS11-01867225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS11-01867OtherKANSAS STATE BOARD OF HEALING ARTS
MO105449OtherMISSOURI STATE BOARD OF REGISTRATION FOR THE HEALING ARTS