Provider Demographics
NPI:1548741903
Name:RUDOLPH, BROOKE ASHLIE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ASHLIE
Last Name:RUDOLPH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3019 CAMELOT CT
Mailing Address - Street 2:
Mailing Address - City:HELMETTA
Mailing Address - State:NJ
Mailing Address - Zip Code:08828-2501
Mailing Address - Country:US
Mailing Address - Phone:732-799-9474
Mailing Address - Fax:
Practice Address - Street 1:70 MURPHY RD # 300A
Practice Address - Street 2:
Practice Address - City:PORT MONMOUTH
Practice Address - State:NJ
Practice Address - Zip Code:07758-1030
Practice Address - Country:US
Practice Address - Phone:732-787-1220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1079731041C0700X
NJ44SL066805001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244371Medicaid