Provider Demographics
NPI:1881163913
Name:DUDLEY, FREDERICK LAMAR
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:LAMAR
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4555 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEARY
Mailing Address - State:GA
Mailing Address - Zip Code:39862-5930
Mailing Address - Country:US
Mailing Address - Phone:229-376-5140
Mailing Address - Fax:404-346-3471
Practice Address - Street 1:1120 W BROAD AVE STE B2
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-4385
Practice Address - Country:US
Practice Address - Phone:229-376-5140
Practice Address - Fax:404-341-3476
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health