Provider Demographics
NPI:1457665051
Name:HUDSON, MARY S (MS,CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:S
Last Name:HUDSON
Suffix:
Gender:F
Credentials:MS,CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2901
Mailing Address - Country:US
Mailing Address - Phone:207-319-1938
Mailing Address - Fax:
Practice Address - Street 1:65 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2901
Practice Address - Country:US
Practice Address - Phone:207-319-1938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP361235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1891919486Medicaid