Provider Demographics
NPI:1023139227
Name:FUDGE, DANIEL LEE (PHD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:LEE
Last Name:FUDGE
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 1:2319 WHITNEY AVE STE 5D
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3534
Mailing Address - Country:US
Mailing Address - Phone:203-288-3554
Mailing Address - Fax:203-248-3690
Practice Address - Street 1:2319 WHITNEY AVE STE 5D
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3534
Practice Address - Country:US
Practice Address - Phone:203-288-2554
Practice Address - Fax:203-248-3690
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3314103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical