Basic Information
| Provider Information | |||||||||
| NPI: | 1972796589 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUDOLPH | ||||||||
| FirstName: | LEWIS | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ED.M., CAGS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 EATON CT | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010022828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4132107042 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 50 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | NORTHAMPTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010603909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135846855 | ||||||||
| FaxNumber: | 4135851355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2007 | ||||||||
| LastUpdateDate: | 08/27/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 5920 | MA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.