Provider Demographics
NPI:1083057137
Name:HUDSON, HEATHER M (LCSW)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:HUDSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W KIRKWOOD AVE STE 222
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-6133
Mailing Address - Country:US
Mailing Address - Phone:812-361-1234
Mailing Address - Fax:
Practice Address - Street 1:101 W KIRKWOOD AVE STE 222
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-6133
Practice Address - Country:US
Practice Address - Phone:812-361-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005660A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1464001OtherMEDICARE PTAN