Provider Demographics
NPI:1245801224
Name:DUDEK, KAITLYN MARIE (MS)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MARIE
Last Name:DUDEK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 POINTE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30328-2755
Mailing Address - Country:US
Mailing Address - Phone:404-932-4140
Mailing Address - Fax:
Practice Address - Street 1:25 POINTE RIDGE DR
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-2755
Practice Address - Country:US
Practice Address - Phone:404-932-4140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-119951106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician