Provider Demographics
NPI:1770845786
Name:RUDOLPH, SUSAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13330 LEOPARD ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410-4400
Mailing Address - Country:US
Mailing Address - Phone:361-504-4028
Mailing Address - Fax:361-288-8409
Practice Address - Street 1:13330 LEOPARD ST
Practice Address - Street 2:SUITE 4
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-4400
Practice Address - Country:US
Practice Address - Phone:361-504-4028
Practice Address - Fax:361-288-8409
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34860103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling