Provider Demographics
NPI:1235487059
Name:DUDLEY, STEPHANIE KAY (LCSW-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KAY
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2336 GODDARD PKWY
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-1126
Mailing Address - Country:US
Mailing Address - Phone:410-334-6961
Mailing Address - Fax:410-334-6362
Practice Address - Street 1:2336 GODDARD PKWY
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-1126
Practice Address - Country:US
Practice Address - Phone:410-334-6961
Practice Address - Fax:410-334-6362
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD183801041C0700X, 1041S0200X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD522156095OtherCOMMERCIAL INS
MD7840093OtherAETNA
MDR968OtherCAREFIRST HMO
MD609550001Medicaid
346646OtherMHN/TRICARE
MDLM49EAOtherCAREFIRST LOCAL
MD522156095OtherCOMMERCIAL INS