Provider Demographics
NPI:1710262233
Name:RUDOLPH, ELIZABETH ANN (LLP)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANN
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 MILLER DR
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:MI
Mailing Address - Zip Code:49224-1140
Mailing Address - Country:US
Mailing Address - Phone:269-832-8803
Mailing Address - Fax:
Practice Address - Street 1:1200 N WEST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2179
Practice Address - Country:US
Practice Address - Phone:517-780-3390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-16
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014357103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical