Provider Demographics
NPI:1528200524
Name:RUDOLPH, LAATASHA (BSW, CSW)
Entity Type:Individual
Prefix:MS
First Name:LAATASHA
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:BSW, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3133
Mailing Address - Country:US
Mailing Address - Phone:307-637-3953
Mailing Address - Fax:307-638-6805
Practice Address - Street 1:604 E 25TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3133
Practice Address - Country:US
Practice Address - Phone:307-637-3953
Practice Address - Fax:307-638-6805
Is Sole Proprietor?:No
Enumeration Date:2009-04-06
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical