Provider Demographics
NPI:1083764617
Name:DUDLEY, MARY KATHRYN (L C A S)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHRYN
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:L C A S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2463
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28151-2463
Mailing Address - Country:US
Mailing Address - Phone:704-471-0010
Mailing Address - Fax:704-471-9696
Practice Address - Street 1:320 E GRAHAM ST STE 3
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-5569
Practice Address - Country:US
Practice Address - Phone:704-471-0110
Practice Address - Fax:704-471-9696
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC992101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111867Medicaid