Provider Demographics
NPI:1023852530
Name:HAGWOOD, RUDOLPH JR
Entity type:Individual
Prefix:
First Name:RUDOLPH
Middle Name:
Last Name:HAGWOOD
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 LONG HILL TER
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06515-1850
Mailing Address - Country:US
Mailing Address - Phone:203-435-2648
Mailing Address - Fax:
Practice Address - Street 1:1635 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-1984
Practice Address - Country:US
Practice Address - Phone:203-335-3518
Practice Address - Fax:203-382-5589
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional