Provider Demographics
NPI:1164660296
Name:HUDSON, CAROLYN (LAC)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:
Last Name:HUDSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3352 N FUTRALL DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4057
Mailing Address - Country:US
Mailing Address - Phone:479-521-5868
Mailing Address - Fax:479-521-6520
Practice Address - Street 1:701 ARKANSAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-2105
Practice Address - Country:US
Practice Address - Phone:870-772-5028
Practice Address - Fax:870-772-5056
Is Sole Proprietor?:No
Enumeration Date:2009-01-28
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ARA1003044101YM0800X
TX12509101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional