Healthcare Provider Details

I. General information

NPI: 1063615805
Provider Name (Legal Business Name): TIFFNEY ANN DUDLEY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1606 WELLINGTON AVE STE C COMMUNITY SUPPORT PROFESSIONALS,LLC
WILMINGTON NC
28401-7704
US

IV. Provider business mailing address

5001 PERTH DR
WILMINGTON NC
28412-7852
US

V. Phone/Fax

Practice location:
  • Phone: 910-799-4505
  • Fax: 910-799-4345
Mailing address:
  • Phone: 910-793-4220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3754
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3754
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: