Provider Demographics
NPI:1548741903
Name:RUDOLPH, BROOKE ASHLIE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ASHLIE
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8131 BAXTER AVE APT 2D
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1316
Mailing Address - Country:US
Mailing Address - Phone:309-231-0822
Mailing Address - Fax:
Practice Address - Street 1:1430 BROADWAY
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11106-4530
Practice Address - Country:US
Practice Address - Phone:718-545-7683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1079731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244371Medicaid