Provider Demographics
NPI:1710057294
Name:DUDLEY, GARY EDWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:EDWARD
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 WINDY HILL RD SE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8664
Mailing Address - Country:US
Mailing Address - Phone:770-953-6401
Mailing Address - Fax:770-953-6015
Practice Address - Street 1:2520 WINDY HILL RD SE
Practice Address - Street 2:SUITE 203
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8664
Practice Address - Country:US
Practice Address - Phone:770-953-6401
Practice Address - Fax:770-953-6015
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY000520103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000117961FMedicaid
GA000117961AMedicaid
GA000117961GMedicaid
GA000117961HMedicaid