=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235487059
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE KAY DUDLEY LCSW-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2012
-----------------------------------------------------
Last Update Date | 09/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2336 GODDARD PKWY
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21801-1126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-334-6961
-----------------------------------------------------
Fax | 410-334-6362
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2336 GODDARD PKWY
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21801-1126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-334-6961
-----------------------------------------------------
Fax | 410-334-6362
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 18380
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041S0200X
-----------------------------------------------------
Taxonomy Name | School Social Worker
-----------------------------------------------------
License Number | 18380
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 18380
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------