Provider Demographics
NPI:1275020612
Name:KUDER, STACEY (LSW, MSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:KUDER
Suffix:
Gender:F
Credentials:LSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1230
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-1230
Mailing Address - Country:US
Mailing Address - Phone:812-471-4511
Mailing Address - Fax:812-471-4514
Practice Address - Street 1:445 N CROSS POINTE BLVD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-4010
Practice Address - Country:US
Practice Address - Phone:812-471-4611
Practice Address - Fax:812-471-4514
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33008162A104100000X
IN34008399A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker