Provider Demographics
NPI:1952400723
Name:RUDOLPH, SIMON ALAN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:SIMON
Middle Name:ALAN
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:LEN
Other - Middle Name:
Other - Last Name:RUDOLPH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5907 VAN HORN RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-3831
Mailing Address - Country:US
Mailing Address - Phone:865-688-4609
Mailing Address - Fax:
Practice Address - Street 1:901 E SUMMIT HILL DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37915-1200
Practice Address - Country:US
Practice Address - Phone:865-524-7483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical