Healthcare Provider Details

I. General information

NPI: 1366455792
Provider Name (Legal Business Name): RYAN R DUDLEY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MEDICAL DR SUITE A
HAMPTON VA
23666-1769
US

IV. Provider business mailing address

300 MEDICAL DR 2ND FLOOR
HAMPTON VA
23666-1765
US

V. Phone/Fax

Practice location:
  • Phone: 757-788-0600
  • Fax: 757-788-0932
Mailing address:
  • Phone: 757-788-0092
  • Fax: 757-788-0969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904005958
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: