Healthcare Provider Details

I. General information

NPI: 1972796589
Provider Name (Legal Business Name): LEWIS CHARLES RUDOLPH ED.M., CAGS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2007
Last Update Date: 08/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 PLEASANT ST
NORTHAMPTON MA
01060-3909
US

IV. Provider business mailing address

4 EATON CT
AMHERST MA
01002-2828
US

V. Phone/Fax

Practice location:
  • Phone: 413-584-6855
  • Fax: 413-585-1355
Mailing address:
  • Phone: 413-210-7042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5920
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: