Provider Demographics
NPI:1669591293
Name:DANA, DUDLEY (PHD)
Entity type:Individual
Prefix:
First Name:DUDLEY
Middle Name:
Last Name:DANA
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 1:815 E FRONT ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-5600
Mailing Address - Country:US
Mailing Address - Phone:406-549-4088
Mailing Address - Fax:
Practice Address - Street 1:815 E FRONT ST STE 1
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-5600
Practice Address - Country:US
Practice Address - Phone:406-549-4088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT225103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0492297Medicaid
MT53090OtherBLUE CROSS BLUE SHIELD
MT5268Medicare ID - Type Unspecified