Provider Demographics
NPI:1538936851
Name:RUDOLPH, JUDY MICHELLE
Entity type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:MICHELLE
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 1:24850 HANCOCK AVE APT J207
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-4136
Mailing Address - Country:US
Mailing Address - Phone:858-401-3334
Mailing Address - Fax:
Practice Address - Street 1:25873 HEMET ST
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-5026
Practice Address - Country:US
Practice Address - Phone:951-765-6955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-06
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist