Provider Demographics
NPI:1205528155
Name:DUDLEY, TRACE JULIUS
Entity type:Individual
Prefix:
First Name:TRACE
Middle Name:JULIUS
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TJ
Other - Middle Name:
Other - Last Name:DUDLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1037 WATERSTONE PARK CIR
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NC
Mailing Address - Zip Code:27278-9888
Mailing Address - Country:US
Mailing Address - Phone:252-702-3026
Mailing Address - Fax:
Practice Address - Street 1:4733 JESSICA DR NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-0853
Practice Address - Country:US
Practice Address - Phone:505-537-9725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2023-0403101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health