Provider Demographics
NPI:1790822369
Name:RUDOLPH, MICHELLE RENA (LCMHC)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:RENA
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6752 PARKER FARM DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-3175
Mailing Address - Country:US
Mailing Address - Phone:910-758-1362
Mailing Address - Fax:
Practice Address - Street 1:6752 PARKER FARM DR STE 100
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-3175
Practice Address - Country:US
Practice Address - Phone:910-758-1362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11881101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health