Healthcare Provider Details

I. General information

NPI: 1356687040
Provider Name (Legal Business Name): JONATHAN ADAM DUDEK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2012
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 MILL ST
PRINCETON ME
04668-3344
US

IV. Provider business mailing address

136 MILL ST
PRINCETON ME
04668-3344
US

V. Phone/Fax

Practice location:
  • Phone: 207-796-5503
  • Fax: 207-796-5528
Mailing address:
  • Phone: 207-796-5503
  • Fax: 207-796-5528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS1103
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1052
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: