Provider Demographics
NPI:1912308933
Name:RUDOLPH, ANDREA SCHREIBMAN (LCSW, MSW, MPH)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:SCHREIBMAN
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:LCSW, MSW, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 KATONA DR STE 19
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-3544
Mailing Address - Country:US
Mailing Address - Phone:203-257-1009
Mailing Address - Fax:
Practice Address - Street 1:60 KATONA DR STE 19
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-3544
Practice Address - Country:US
Practice Address - Phone:203-257-1009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-09
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT86421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008055415Medicaid
CT008055415Medicaid