Healthcare Provider Details

I. General information

NPI: 1922914936
Provider Name (Legal Business Name): BRISTAL GRACE RUDOLPH LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 E HOLLY RD
HOLLY MI
48442-9664
US

IV. Provider business mailing address

14470 N HOLLY RD
HOLLY MI
48442-8418
US

V. Phone/Fax

Practice location:
  • Phone: 248-328-3200
  • Fax:
Mailing address:
  • Phone: 248-328-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number6851120022
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: