Provider Demographics
NPI:1689219099
Name:RUDOLPH, MEGHAN LEE
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:LEE
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 1:29 SNOWBERRY LN
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-1130
Mailing Address - Country:US
Mailing Address - Phone:203-913-2429
Mailing Address - Fax:
Practice Address - Street 1:29 SNOWBERRY LN
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-1130
Practice Address - Country:US
Practice Address - Phone:203-913-2429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-08
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5806101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional