Provider Demographics
NPI:1184251647
Name:FUDALLY, JOSEPHINE
Entity type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:
Last Name:FUDALLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4757 HIAWATHA AVE UNIT 607
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-4491
Mailing Address - Country:US
Mailing Address - Phone:715-817-3768
Mailing Address - Fax:
Practice Address - Street 1:1308 GREENWOOD CT
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-4452
Practice Address - Country:US
Practice Address - Phone:512-458-0260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst