Provider Demographics
NPI:1912530122
Name:RUDOLPH, CHRISTINE E
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:E
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 MEADOWVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-2382
Mailing Address - Country:US
Mailing Address - Phone:847-409-3864
Mailing Address - Fax:
Practice Address - Street 1:5225 OLD ORCHARD RD STE 17
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1027
Practice Address - Country:US
Practice Address - Phone:847-271-6840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-16
Last Update Date:2020-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2227285103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst