Provider Demographics
NPI:1295784965
Name:DUDLEY, SYBIL W (LCSW)
Entity type:Individual
Prefix:MS
First Name:SYBIL
Middle Name:W
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:SYBIL
Other - Middle Name:W
Other - Last Name:MOULTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 234
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-0234
Mailing Address - Country:US
Mailing Address - Phone:912-756-7136
Mailing Address - Fax:912-756-7146
Practice Address - Street 1:50 FORD WAY STE 103
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-4438
Practice Address - Country:US
Practice Address - Phone:912-756-7136
Practice Address - Fax:912-756-7146
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW#0029241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA916944984AMedicaid
GA916944984AMedicaid