Provider Demographics
NPI:1174910855
Name:RUDOLPH, MARY
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
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 1:4190 E LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16511-1355
Mailing Address - Country:US
Mailing Address - Phone:814-616-2858
Mailing Address - Fax:814-616-2860
Practice Address - Street 1:4190 E LAKE RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16511
Practice Address - Country:US
Practice Address - Phone:814-616-2858
Practice Address - Fax:814-616-2860
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CW019986101YM0800X
PASW131533104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker