Provider Demographics
NPI:1366295180
Name:RUDOLPH, GERALD BRENT (LAC)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:BRENT
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2216 BOOTHILL CT STE 3
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-7215
Mailing Address - Country:US
Mailing Address - Phone:406-600-5007
Mailing Address - Fax:
Practice Address - Street 1:2216 BOOTHILL CT STE 3
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-7215
Practice Address - Country:US
Practice Address - Phone:406-600-5007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-10
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-70217101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)