Healthcare Provider Details

I. General information

NPI: 1235536459
Provider Name (Legal Business Name): BRITTANY RUDOLPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 BON AIR RD UNIT B
GREENBRAE CA
94904-1702
US

IV. Provider business mailing address

2600 S EL CAMINO REAL SUITE #200
SAN MATEO CA
94403-2380
US

V. Phone/Fax

Practice location:
  • Phone: 415-473-6797
  • Fax:
Mailing address:
  • Phone: 650-393-8904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: