Provider Demographics
NPI:1063615805
Name:DUDLEY, TIFFNEY ANN (LPC)
Entity type:Individual
Prefix:MS
First Name:TIFFNEY
Middle Name:ANN
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 PERTH DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-7852
Mailing Address - Country:US
Mailing Address - Phone:910-793-4220
Mailing Address - Fax:
Practice Address - Street 1:1606 WELLINGTON AVE STE C
Practice Address - Street 2:COMMUNITY SUPPORT PROFESSIONALS,LLC
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7704
Practice Address - Country:US
Practice Address - Phone:910-799-4505
Practice Address - Fax:910-799-4345
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3754101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3754OtherNC LICENSE #