Provider Demographics
NPI:1568812899
Name:RUDOLPH, DEREK (CMT)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1999 S MAIN ST
Mailing Address - Street 2:STE 303 B
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-6634
Mailing Address - Country:US
Mailing Address - Phone:540-798-7525
Mailing Address - Fax:
Practice Address - Street 1:1999 S MAIN ST
Practice Address - Street 2:STE 303 B
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-6634
Practice Address - Country:US
Practice Address - Phone:540-798-7525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019013520225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist