Healthcare Provider Details

I. General information

NPI: 1881163913
Provider Name (Legal Business Name): FREDERICK LAMAR DUDLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2018
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W BROAD AVE STE B2
ALBANY GA
31707-4385
US

IV. Provider business mailing address

4555 E MAIN ST
LEARY GA
39862-5930
US

V. Phone/Fax

Practice location:
  • Phone: 229-376-5140
  • Fax: 404-341-3476
Mailing address:
  • Phone: 229-376-5140
  • Fax: 404-346-3471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: