Provider Demographics
NPI:1376047845
Name:HUDSON, BERTINA ANN (MFT)
Entity Type:Individual
Prefix:
First Name:BERTINA
Middle Name:ANN
Last Name:HUDSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 SILVER CRES
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92603-3609
Mailing Address - Country:US
Mailing Address - Phone:949-212-2823
Mailing Address - Fax:
Practice Address - Street 1:366 SAN MIGUEL DR STE 309
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7810
Practice Address - Country:US
Practice Address - Phone:949-212-2823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT35057106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist