Provider Demographics
NPI:1366566358
Name:DUDLEY, MARTHA FAIRCHILD (LCPC)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:FAIRCHILD
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:LASS
Other - Middle Name:
Other - Last Name:DUDLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC
Mailing Address - Street 1:612 E MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3719
Mailing Address - Country:US
Mailing Address - Phone:406-539-0300
Mailing Address - Fax:406-522-0286
Practice Address - Street 1:612 E MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3719
Practice Address - Country:US
Practice Address - Phone:406-539-0300
Practice Address - Fax:406-522-0286
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1037101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0255102Medicaid