Provider Demographics
NPI:1285937722
Name:SMITH, RUDOLPH CHARLES
Entity type:Individual
Prefix:MR
First Name:RUDOLPH
Middle Name:CHARLES
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7935 PHAETON DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-4212
Mailing Address - Country:US
Mailing Address - Phone:510-569-6776
Mailing Address - Fax:510-569-7917
Practice Address - Street 1:2580 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-1160
Practice Address - Country:US
Practice Address - Phone:510-444-9655
Practice Address - Fax:510-444-9955
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS28481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical