Provider Demographics
NPI:1013073162
Name:RUDOLPH, ALAN (MS, MFT)
Entity type:Individual
Prefix:MR
First Name:ALAN
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 SAMOA WAY
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-4653
Mailing Address - Country:US
Mailing Address - Phone:310-230-0045
Mailing Address - Fax:
Practice Address - Street 1:5535 BALBOA BLVD
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1516
Practice Address - Country:US
Practice Address - Phone:818-788-2738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC13530106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist