Provider Demographics
NPI:1912529256
Name:DUDLEY, BRENT THOMAS (LCSW)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:THOMAS
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21211 NW 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-1151
Mailing Address - Country:US
Mailing Address - Phone:786-985-3618
Mailing Address - Fax:
Practice Address - Street 1:16531 NW 18TH AVE
Practice Address - Street 2:
Practice Address - City:OPA LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054-6617
Practice Address - Country:US
Practice Address - Phone:786-985-3618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-09
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW165761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty