Provider Demographics
NPI:1104059567
Name:SMITH-RUDOLPH, LAVERNE D
Entity type:Individual
Prefix:MRS
First Name:LAVERNE
Middle Name:D
Last Name:SMITH-RUDOLPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17131 GITRE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205-3161
Mailing Address - Country:US
Mailing Address - Phone:313-245-4357
Mailing Address - Fax:313-371-6139
Practice Address - Street 1:17131 GITRE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-3161
Practice Address - Country:US
Practice Address - Phone:313-245-4357
Practice Address - Fax:313-371-6139
Is Sole Proprietor?:No
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)