Provider Demographics
NPI:1629546775
Name:RUDOLPH, JULIE MARIE (LISW-S)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:MARIE
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 WEST 25TH STREET
Mailing Address - Street 2:MOB-2
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-3108
Mailing Address - Country:US
Mailing Address - Phone:216-363-2122
Mailing Address - Fax:440-312-9251
Practice Address - Street 1:1730 W 25TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-3170
Practice Address - Country:US
Practice Address - Phone:216-363-2122
Practice Address - Fax:440-312-9251
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.00094571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical