Individual
DR. TERRY LEE RUDOLPH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PH.D
Contact information
Practice address
25779 KELLY ROAD, ROSEVILLE, MI 48066-4973
(586) 774-7987
(586) 774-7263
Mailing address
25779 KELLY ROAD, ROSEVILLE, MI 48066-4973
(586) 774-7987
(586) 774-7263
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
6301003357
MI
103TC0700X
Clinical Psychologist
Primary
003357
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
68-0-E0-4564-0
BLUE CROSS/BLUE SHIELD
MI
Enumeration date
07/19/2005
Last updated
03/08/2011
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