Provider Demographics
NPI:1902466279
Name:RUDOLPH-DAVIS, ANNETTE (CDCA)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:RUDOLPH-DAVIS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19002 FAIRWAY AVENUE
Mailing Address - Street 2:FAIRWAY AVE
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137
Mailing Address - Country:US
Mailing Address - Phone:216-415-4324
Mailing Address - Fax:
Practice Address - Street 1:19002 FAIRWAY AVE
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137
Practice Address - Country:US
Practice Address - Phone:216-415-4324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1901100-TRNE104100000X
OH171M00000X, 251S00000X
OH181950101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health