Provider Demographics
NPI:1245386788
Name:DUDLEY, ANDREA DENICE (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:DENICE
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:704 W CHICKASAW AVE
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-4224
Mailing Address - Country:US
Mailing Address - Phone:918-630-9729
Mailing Address - Fax:918-775-6165
Practice Address - Street 1:301 J T STITES BLVD
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-9302
Practice Address - Country:US
Practice Address - Phone:918-775-9150
Practice Address - Fax:918-775-4790
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3492101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional