Provider Demographics
NPI:1417232810
Name:DUDKIN, MELLIE BAUTISTA
Entity type:Individual
Prefix:MRS
First Name:MELLIE
Middle Name:BAUTISTA
Last Name:DUDKIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3288 EL CAJON BLVD
Mailing Address - Street 2:SUITE 13
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-1430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3288 EL CAJON BLVD
Practice Address - Street 2:SUITE 13
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-1430
Practice Address - Country:US
Practice Address - Phone:619-521-5720
Practice Address - Fax:619-521-5728
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health