Provider Demographics
NPI:1184752602
Name:DUDGEON, THOMAS BOONE (PHD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:BOONE
Last Name:DUDGEON
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 1:6066 STRATHMOOR DR
Mailing Address - Street 2:3C
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6633
Mailing Address - Country:US
Mailing Address - Phone:815-399-9303
Mailing Address - Fax:815-399-9306
Practice Address - Street 1:6066 STRATHMOOR DR
Practice Address - Street 2:3C
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6633
Practice Address - Country:US
Practice Address - Phone:815-399-9303
Practice Address - Fax:815-399-9306
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205900Medicare ID - Type Unspecified