Healthcare Provider Details

I. General information

NPI: 1629557814
Provider Name (Legal Business Name): CAROLYN RUDOLPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 READING RD
CINCINNATI OH
45202-1357
US

IV. Provider business mailing address

7691 5 MILE RD STE 301
CINCINNATI OH
45230-4348
US

V. Phone/Fax

Practice location:
  • Phone: 513-768-6924
  • Fax:
Mailing address:
  • Phone: 513-421-3504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number166026
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: