Provider Demographics
NPI:1477562924
Name:RUDOLPH, SARA LYNN (MA)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:LYNN
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 S CEDARBLUFF CT
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-2979
Mailing Address - Country:US
Mailing Address - Phone:864-313-0074
Mailing Address - Fax:
Practice Address - Street 1:6 S CEDARBLUFF CT
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-2979
Practice Address - Country:US
Practice Address - Phone:864-313-0074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3851104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC301100Medicaid
SC301100Medicaid