Provider Demographics
NPI:1770004731
Name:DUDLEY, SARA JEAN (LLBSW)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:JEAN
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:LLBSW
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:JEAN
Other - Last Name:GROULX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4224
Mailing Address - Country:US
Mailing Address - Phone:989-797-3400
Mailing Address - Fax:989-799-0206
Practice Address - Street 1:500 HANCOCK ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4224
Practice Address - Country:US
Practice Address - Phone:989-797-3400
Practice Address - Fax:989-799-0206
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2019-11-08
Deactivation Date:2019-07-18
Deactivation Code:
Reactivation Date:2019-08-07
Provider Licenses
StateLicense IDTaxonomies
175T00000X
MI6802090483171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG642758385640Medicaid