Provider Demographics
NPI:1124727227
Name:RUDOLPH, LADWINA DENICE (LCPC)
Entity type:Individual
Prefix:
First Name:LADWINA
Middle Name:DENICE
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-2154
Mailing Address - Country:US
Mailing Address - Phone:773-301-0138
Mailing Address - Fax:
Practice Address - Street 1:2259 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4233
Practice Address - Country:US
Practice Address - Phone:312-285-2982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180015025101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional