Provider Demographics
NPI:1942492517
Name:DUDLEY, CHARLES DOY (MED LCPC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DOY
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:MED LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60146-8247
Mailing Address - Country:US
Mailing Address - Phone:815-522-2417
Mailing Address - Fax:815-397-2712
Practice Address - Street 1:5804 ELAINE DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2435
Practice Address - Country:US
Practice Address - Phone:815-397-7654
Practice Address - Fax:815-397-2712
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional