Provider Demographics
NPI:1477529972
Name:DUDLEY, LORI (PHD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4404
Mailing Address - Country:US
Mailing Address - Phone:540-853-0900
Mailing Address - Fax:540-853-0511
Practice Address - Street 1:4348 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-0720
Practice Address - Country:US
Practice Address - Phone:540-769-0976
Practice Address - Fax:540-857-5385
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810-003042103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010047668Medicaid
VA010194644Medicaid
VA010194679Medicaid
VA7712910Medicaid
VA010194652Medicaid
VA010077656Medicaid
VA010077672Medicaid
VA010194652Medicaid
VA010077672Medicaid
VA680014907Medicare PIN
VA00W537C08Medicare PIN
VAP55275Medicare UPIN