Provider Demographics
NPI:1477091908
Name:RUDOLPH COUNSELING
Entity Type:Organization
Organization Name:RUDOLPH COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-354-0604
Mailing Address - Street 1:12570 DORR RD
Mailing Address - Street 2:
Mailing Address - City:ROCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61072-2839
Mailing Address - Country:US
Mailing Address - Phone:815-988-6687
Mailing Address - Fax:
Practice Address - Street 1:12570 DORR RD
Practice Address - Street 2:
Practice Address - City:ROCKTON
Practice Address - State:IL
Practice Address - Zip Code:61072-2839
Practice Address - Country:US
Practice Address - Phone:815-988-6687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007114251S00000X
WI4570125251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1750619318Medicaid
IL1750619318Medicaid