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NPI Code Detail

MEDICARE: MR. SIMON ALAN RUDOLPH LCSW

MEDICARE: MR. SIMON ALAN RUDOLPH LCSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker3075TN

General Provider Information

NPI Number : 1952400723
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. SIMON ALAN RUDOLPH LCSW
Provider Business Mailing Address
First Line : 5907 VAN HORN RD
Second Line :
City : KNOXVILLE
State : TN
Zip : 37918-3831
Country : US
Telephone Number : 865-688-4609
Fax Number :
Provider Business Practice Location Address
First Line : 901 E SUMMIT HILL DR
Second Line :
City : KNOXVILLE
State : TN
Zip : 37915-1200
Country : US
Telephone Number : 865-524-7483
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/21/2006
Last Update Date : 07/08/2007

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