Provider Demographics
NPI:1578126850
Name:RUDOLPH, DONALD ADAM MICHAEL
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:ADAM MICHAEL
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3850
Mailing Address - Country:US
Mailing Address - Phone:406-587-2477
Mailing Address - Fax:406-587-9526
Practice Address - Street 1:1315 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3850
Practice Address - Country:US
Practice Address - Phone:406-587-2477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program