Provider Demographics
NPI:1346325586
Name:DUDLEY, ELLEN LEE (MA LPC CRC)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:LEE
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:MA LPC CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 SPENCER CT
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-3463
Mailing Address - Country:US
Mailing Address - Phone:910-274-6757
Mailing Address - Fax:910-344-1206
Practice Address - Street 1:2018 EASTWOOD RD
Practice Address - Street 2:SUITE 316
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-7228
Practice Address - Country:US
Practice Address - Phone:910-344-0480
Practice Address - Fax:910-344-1206
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3295101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103368Medicaid