Provider Demographics
NPI:1538597471
Name:RUDOLPH, LORI (PHD)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LORI
Other - Middle Name:HELENE
Other - Last Name:RUDOLPH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:2704 LOS ANAYAS RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-2934
Mailing Address - Country:US
Mailing Address - Phone:505-550-9553
Mailing Address - Fax:
Practice Address - Street 1:2704 LOS ANAYAS RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-2934
Practice Address - Country:US
Practice Address - Phone:505-550-9553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0245101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional