Provider Demographics
NPI:1720564917
Name:RUDOLPH, KENNETH EARL
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:EARL
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 1:1103 WEST STAN SCHLUETER LOOP
Mailing Address - Street 2:BUILDING A SUITE 100
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549
Mailing Address - Country:US
Mailing Address - Phone:254-213-7847
Mailing Address - Fax:254-312-2002
Practice Address - Street 1:1103 WEST STAN SCHLUETER LOOP
Practice Address - Street 2:BUILDING A SUITE 100
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549
Practice Address - Country:US
Practice Address - Phone:254-213-7847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62252104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker