Provider Demographics
NPI:1215107503
Name:RUDOLPH, GINA (PSYD)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 ROUTE 9 N
Mailing Address - Street 2:SUITE # 6
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-8561
Mailing Address - Country:US
Mailing Address - Phone:732-239-7208
Mailing Address - Fax:732-239-7208
Practice Address - Street 1:205 ROUTE 9 N
Practice Address - Street 2:SUITE # 6
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-8561
Practice Address - Country:US
Practice Address - Phone:732-239-7208
Practice Address - Fax:732-239-7208
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-03
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4513103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical