Terry Lee Rudolph, PH.D

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

003357 Issued in MI

Practice address

25779 Kelly Road
Roseville, MI 48066-4973

Phone

(586) 774-7987

Fax

(586) 774-7263

NPI assigned

Jul 19, 2005

Sex

Male

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Other identifiers 1

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.

• Geriatric Psychiatric Services PLLC

  • Clinical Psychologist
  • Indianapolis, IN
  • NPI 1073753323
  NPD (past)

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

{
    "created_epoch": "1121731200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1299542400000",
    "number": "1154320489",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "25779 KELLY ROAD",
            "city": "ROSEVILLE",
            "state": "MI",
            "postal_code": "480664973",
            "telephone_number": "586-774-7987",
            "fax_number": "586-774-7263"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "25779 KELLY ROAD",
            "city": "ROSEVILLE",
            "state": "MI",
            "postal_code": "480664973",
            "telephone_number": "586-774-7987",
            "fax_number": "586-774-7263"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "RUDOLPH",
        "first_name": "TERRY",
        "middle_name": "LEE",
        "name_prefix": "Dr.",
        "credential": "PH.D",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-07-19",
        "last_updated": "2011-03-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "MI",
            "license": "6301003357",
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "MI",
            "license": "003357",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS/BLUE SHIELD",
            "identifier": "68-0-E0-4564-0",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Roseville RX, Inc.
• Roseville Urgent Care, PC
• Leona Rossbach
• Debra J. Rossie, CNM, MSN
• Briana Roy, LCSW
• Jennifer Simpson Ruprecht, PA
• Diane Gail Russell, M.S.W.
• Karen Marie Rutherford, DDS
• Fadi-Jean Saad, M.D.
• Sabah Internal Medicine PLLC

• Clinical Psychologist in Roseville, MI
• Providers in Roseville, MI by specialty
• Clinical Psychologist in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 8, 2011; 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.