Provider Demographics
NPI:1134327562
Name:HUDSON, CANDICE MARIE (RPT)
Entity Type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:MARIE
Last Name:HUDSON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8025 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:MO
Mailing Address - Zip Code:63016-2117
Mailing Address - Country:US
Mailing Address - Phone:314-220-9830
Mailing Address - Fax:
Practice Address - Street 1:13612 BIG BEND RD
Practice Address - Street 2:
Practice Address - City:VALLEY PARK
Practice Address - State:MO
Practice Address - Zip Code:63088-1447
Practice Address - Country:US
Practice Address - Phone:314-220-9830
Practice Address - Fax:636-825-2323
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114776225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist