Provider Demographics
NPI:1265504682
Name:DUDLEY, TIM M (LMT)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:M
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5316 ANGELES AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34235-3406
Mailing Address - Country:US
Mailing Address - Phone:941-525-4190
Mailing Address - Fax:
Practice Address - Street 1:3150 SOUTHGATE CIR STE C
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-5515
Practice Address - Country:US
Practice Address - Phone:941-525-4190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA9015225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist