Provider Demographics
NPI:1427538495
Name:DUDLEY, WALTERINA ANNE
Entity Type:Individual
Prefix:
First Name:WALTERINA
Middle Name:ANNE
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3734 DANUBE DR
Mailing Address - Street 2:
Mailing Address - City:GROVEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43125-9530
Mailing Address - Country:US
Mailing Address - Phone:614-587-7372
Mailing Address - Fax:
Practice Address - Street 1:3042 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-3653
Practice Address - Country:US
Practice Address - Phone:614-487-7805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-18
Last Update Date:2018-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician