Provider Demographics
NPI:1083381495
Name:HUDDLESTON, ALLIE MARIE
Entity Type:Individual
Prefix:MS
First Name:ALLIE
Middle Name:MARIE
Last Name:HUDDLESTON
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 1:3506 GABBY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8684
Mailing Address - Country:US
Mailing Address - Phone:309-533-8486
Mailing Address - Fax:
Practice Address - Street 1:2103 E WASHINGTON ST STE 2D
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4365
Practice Address - Country:US
Practice Address - Phone:309-822-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL178.018526101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program