Provider Demographics
NPI:1861619264
Name:DUDLEY, THERESA ANN (LCSW, CADC1)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:LCSW, CADC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 902
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-0902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1904 ELM ST
Practice Address - Street 2:SUITE 5
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2553
Practice Address - Country:US
Practice Address - Phone:503-803-0601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL36371041C0700X
OR01-11-18101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)