Provider Demographics
NPI:1508633413
Name:CHUDACOFF, KIRSTEN ANN (ACSW)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:ANN
Last Name:CHUDACOFF
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14642 NEWPORT AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6059
Mailing Address - Country:US
Mailing Address - Phone:714-247-0300
Mailing Address - Fax:714-259-1598
Practice Address - Street 1:1 HOPE DR
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92782-0221
Practice Address - Country:US
Practice Address - Phone:714-247-0300
Practice Address - Fax:714-259-1598
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1195141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical