Basic Information
| Provider Information | |||||||||
| NPI: | 1073542833 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUDLEY | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RABOLD | ||||||||
| OtherFirstName: | KATIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2551 COORS BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871201213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 750 MORRIS RD SE | ||||||||
| Address2: | |||||||||
| City: | LOS LUNAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870315242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058662318 | ||||||||
| FaxNumber: | 5058879579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 06/11/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | T-0092361 | NM | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 119801 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.