Provider Demographics
NPI:1588819742
Name:MENCHACA, RUDOLOFO (LMSW)
Entity Type:Individual
Prefix:
First Name:RUDOLOFO
Middle Name:
Last Name:MENCHACA
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 RICHARDSON ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3548
Mailing Address - Country:US
Mailing Address - Phone:810-984-5156
Mailing Address - Fax:810-984-5228
Practice Address - Street 1:1209 RICHARDSON ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3548
Practice Address - Country:US
Practice Address - Phone:810-984-5156
Practice Address - Fax:810-984-5228
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010884381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OM85900Medicare UPIN