Provider Demographics
NPI:1952896052
Name:RUDOLPH, JOHN (LPC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1075
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA STATION
Mailing Address - State:OH
Mailing Address - Zip Code:44028-1075
Mailing Address - Country:US
Mailing Address - Phone:440-529-9419
Mailing Address - Fax:440-588-8764
Practice Address - Street 1:35895 ROYALTON RD
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:OH
Practice Address - Zip Code:44044-9587
Practice Address - Country:US
Practice Address - Phone:440-529-9419
Practice Address - Fax:440-588-8764
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-30
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.0007827101YM0800X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0298176Medicaid