Provider Demographics
NPI:1487827499
Name:RUDOLPH, KIMMY (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMMY
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 TIMBERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CRANBERRY
Mailing Address - State:PA
Mailing Address - Zip Code:16319-2309
Mailing Address - Country:US
Mailing Address - Phone:814-657-2918
Mailing Address - Fax:
Practice Address - Street 1:351 TIMBERWOOD LN
Practice Address - Street 2:
Practice Address - City:CRANBERRY
Practice Address - State:PA
Practice Address - Zip Code:16319-2309
Practice Address - Country:US
Practice Address - Phone:814-657-2918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL008814235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist