Provider Demographics
NPI:1891441812
Name:RUDOLF, KELLY ANNE (MA, LAC, NCC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:RUDOLF
Suffix:
Gender:F
Credentials:MA, LAC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5890 N GALLERY LN
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-5893
Mailing Address - Country:US
Mailing Address - Phone:516-592-7369
Mailing Address - Fax:
Practice Address - Street 1:115 S MCCORMICK ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-4738
Practice Address - Country:US
Practice Address - Phone:928-756-0662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-20667101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health