Provider Demographics
NPI:1477050284
Name:DUDLEY, CRYSTAL DIONNE (LPC, LCDC)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:DIONNE
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 STONE RD STE 103
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-5494
Mailing Address - Country:US
Mailing Address - Phone:469-608-0295
Mailing Address - Fax:
Practice Address - Street 1:1100 STONE RD STE 103
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-5494
Practice Address - Country:US
Practice Address - Phone:469-608-0295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3921009-01Medicaid
TX3921009-01Medicaid