Provider Demographics
NPI:1972796589
Name:RUDOLPH, LEWIS CHARLES (EDM, CAGS)
Entity Type:Individual
Prefix:MR
First Name:LEWIS
Middle Name:CHARLES
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:EDM, CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 EATON CT
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01002-2828
Mailing Address - Country:US
Mailing Address - Phone:413-210-7042
Mailing Address - Fax:
Practice Address - Street 1:50 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3909
Practice Address - Country:US
Practice Address - Phone:413-584-6855
Practice Address - Fax:413-585-1355
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5920101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health