Provider Demographics
NPI:1073101127
Name:HUDELSON, MELLONEY
Entity Type:Individual
Prefix:
First Name:MELLONEY
Middle Name:
Last Name:HUDELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 MADELINE WAY APT 215
Mailing Address - Street 2:
Mailing Address - City:WHITE HOUSE
Mailing Address - State:TN
Mailing Address - Zip Code:37188-2504
Mailing Address - Country:US
Mailing Address - Phone:615-756-8589
Mailing Address - Fax:
Practice Address - Street 1:324 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2706
Practice Address - Country:US
Practice Address - Phone:615-756-8589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5206101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty