Healthcare Provider Details

I. General information

NPI: 1225739709
Provider Name (Legal Business Name): RUDOLPH WOODY CACII,CODC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 NEW YORK AVE NW FL W5
WASHINGTON DC
20005-4701
US

IV. Provider business mailing address

1313 NEW YORK AVE. N.W. 5TH FL
WASHINGTON DC
20005
US

V. Phone/Fax

Practice location:
  • Phone: 202-737-6191
  • Fax:
Mailing address:
  • Phone: 202-737-6191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCACII1174
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: