Healthcare Provider Details

I. General information

NPI: 1841287950
Provider Name (Legal Business Name): AMANDA JANE DUDDLESON MSW, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 E MADISON ST
SOUTH BEND IN
46617-2322
US

IV. Provider business mailing address

415 E MADISON ST P.O. BOX 1240
SOUTH BEND IN
46617-2322
US

V. Phone/Fax

Practice location:
  • Phone: 574-280-1234
  • Fax: 574-280-4605
Mailing address:
  • Phone: 574-280-1234
  • Fax: 574-280-4605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: