Provider Demographics
NPI:1740362474
Name:KUDLESS, MARY W (MSN RN CS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:W
Last Name:KUDLESS
Suffix:
Gender:F
Credentials:MSN RN CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3834 N TAZEWELL ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22207-4555
Mailing Address - Country:US
Mailing Address - Phone:703-241-5584
Mailing Address - Fax:703-237-4999
Practice Address - Street 1:3834 N TAZEWELL ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22207-4555
Practice Address - Country:US
Practice Address - Phone:703-241-5584
Practice Address - Fax:703-237-4999
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0015000370101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor