Provider Demographics
NPI:1730668906
Name:RUDOLPH, ELLAINA RENEE
Entity Type:Individual
Prefix:
First Name:ELLAINA
Middle Name:RENEE
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 1:1989 VIRGINIA PARK ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206-2421
Mailing Address - Country:US
Mailing Address - Phone:313-784-6761
Mailing Address - Fax:
Practice Address - Street 1:12501 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3243
Practice Address - Country:US
Practice Address - Phone:313-865-1580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)