Provider Demographics
NPI:1326304734
Name:DUDEK, DIANE KATHRYN (CADC-II, ICADC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:KATHRYN
Last Name:DUDEK
Suffix:
Gender:F
Credentials:CADC-II, ICADC
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:KATHRYN
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADC-II, ICADC
Mailing Address - Street 1:939 N D ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3519
Mailing Address - Country:US
Mailing Address - Phone:909-889-6519
Mailing Address - Fax:
Practice Address - Street 1:939 N D ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3519
Practice Address - Country:US
Practice Address - Phone:909-889-6519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA05190315101YA0400X
CAI9841210101YM0800X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
A05190315OtherCALIFORNIA CONSORTIUM OF ADDICTION PROGRAMS AND PROFESSIONALS
CAC5950912OtherCALIFORNIA BOARD OF ALCOHOL AND DRUG COUNSELORS