Basic Information
Provider Information | |||||||||
NPI: | 1558382614 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUDLEY | ||||||||
FirstName: | LAURA | ||||||||
MiddleName: | HARRISON | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7594 | ||||||||
Address2: |   | ||||||||
City: | ROCKY MOUNT | ||||||||
State: | NC | ||||||||
PostalCode: | 278040594 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2524430808 | ||||||||
FaxNumber: | 2524519032 | ||||||||
Practice Location | |||||||||
Address1: | 901 N WINSTEAD AVE | ||||||||
Address2: |   | ||||||||
City: | ROCKY MOUNT | ||||||||
State: | NC | ||||||||
PostalCode: | 278048467 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2529370277 | ||||||||
FaxNumber: | 2529370287 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2006 | ||||||||
LastUpdateDate: | 08/03/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 903 | NC | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 7210230 | 05 | NC |   | MEDICAID | 126MY | 01 | NC | BCBS | OTHER | 195518 | 01 | NC | MEDCOST | OTHER | 2241335 | 01 | NC | UNITED HEALTH CARE | OTHER |