Liza Raquel Rudolph, PH.D.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

200251030 Issued in IN

Practice address

255 E Sunset LN
West Lafayette, IN 47906-2456

Phone

(765) 532-9084

Fax

(765) 447-9659

NPI assigned

May 30, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 4

Other names 1

• Mrs. Liza Raquel Simental Professional name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Willowstone Family Services

  • Mental Health Counselor
  • Lafayette, IN
  • NPI 1780742874
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1148947200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1462406400000",
    "number": "1003863382",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3884",
            "city": "WEST LAFAYETTE",
            "state": "IN",
            "postal_code": "479963884",
            "telephone_number": "765-532-9084",
            "fax_number": "765-447-9659"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "255 E SUNSET LN",
            "city": "WEST LAFAYETTE",
            "state": "IN",
            "postal_code": "479062456",
            "telephone_number": "765-532-9084",
            "fax_number": "765-447-9659"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "RUDOLPH",
        "first_name": "LIZA",
        "middle_name": "RAQUEL",
        "name_prefix": "Mrs.",
        "credential": "PH.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-05-30",
        "last_updated": "2016-05-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "IN",
            "license": "200251030",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS/BLUE SHIELD",
            "identifier": "000000378693",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VALUE OPTIONS",
            "identifier": "251277",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200251030B",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MAGELLAN",
            "identifier": "284435000",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "LIZA",
            "last_name": "SIMENTAL",
            "middle_name": "RAQUEL",
            "prefix": "MRS.",
            "credential": "PH.D.",
            "code": "2",
            "type": "Professional Name"
        }
    ]
}

• Rachel Ross
• Megan Rowe, ANP-C
• Olivia Christine Rowe
• Risha E Ruano-Zin, LMHC
• Trexie Mercado Rudd, PHARMD
• Emily Rupp
• Cooper Rusch
• Bailey Rush
• Tiffany Rush
• Grace Noelle Rusher

• Clinical Psychologist in West Lafayette, IN
• Providers in West Lafayette, IN by specialty
• Clinical Psychologist in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 5, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.