Provider Demographics
NPI:1336900596
Name:KUDLEK, MARYANNE
Entity Type:Individual
Prefix:MRS
First Name:MARYANNE
Middle Name:
Last Name:KUDLEK
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 1:5029 HENSHAW RD
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-4546
Mailing Address - Country:US
Mailing Address - Phone:631-790-5122
Mailing Address - Fax:
Practice Address - Street 1:5029 HENSHAW RD
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-4546
Practice Address - Country:US
Practice Address - Phone:631-790-5122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC161301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty