Provider Demographics
NPI:1972196657
Name:DUDLEY, ASHLEY MARION (LMT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MARION
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5262 NE 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-6240
Mailing Address - Country:US
Mailing Address - Phone:216-272-8757
Mailing Address - Fax:
Practice Address - Street 1:4927 NE 30TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-7007
Practice Address - Country:US
Practice Address - Phone:503-281-0681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-14
Last Update Date:2021-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25726225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist