1235487059 NPI number — STEPHANIE KAY DUDLEY LCSW-C

Table of content: STEPHANIE KAY DUDLEY LCSW-C (NPI 1235487059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235487059 NPI number — STEPHANIE KAY DUDLEY LCSW-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUDLEY
Provider First Name:
STEPHANIE
Provider Middle Name:
KAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235487059
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2336 GODDARD PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALISBURY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21801-1126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-334-6961
Provider Business Mailing Address Fax Number:
410-334-6362

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2336 GODDARD PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALISBURY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21801-1126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-334-6961
Provider Business Practice Location Address Fax Number:
410-334-6362
Provider Enumeration Date:
08/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  18380 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041S0200X , with the licence number: 18380 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: 18380 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 522156095 . This is a "COMMERCIAL INS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 7840093 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: R968 . This is a "CAREFIRST HMO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 609550001 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 346646 . This is a "MHN/TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: LM49EA . This is a "CAREFIRST LOCAL" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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