Provider Demographics
NPI:1508873233
Name:HUDSON, JOAN RAE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:RAE
Last Name:HUDSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 W MOSS AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1830
Mailing Address - Country:US
Mailing Address - Phone:512-638-3470
Mailing Address - Fax:
Practice Address - Street 1:7717 N ORANGE PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-9323
Practice Address - Country:US
Practice Address - Phone:309-589-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.004809103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical