Healthcare Provider Details

I. General information

NPI: 1629546775
Provider Name (Legal Business Name): JULIE MARIE RUDOLPH LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2018
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 W 25TH ST
CLEVELAND OH
44113-3170
US

IV. Provider business mailing address

1730 WEST 25TH STREET MOB-2
CLEVELAND OH
44113-3108
US

V. Phone/Fax

Practice location:
  • Phone: 216-363-2122
  • Fax: 440-312-9251
Mailing address:
  • Phone: 216-363-2122
  • Fax: 440-312-9251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.0009457
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: