Provider Demographics
NPI:1558800748
Name:HUDSON, KELLEY ANNE (LADC)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:ANNE
Last Name:HUDSON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:ANNE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2739 RUSSELL AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-1064
Mailing Address - Country:US
Mailing Address - Phone:763-438-0004
Mailing Address - Fax:
Practice Address - Street 1:1956 FERONIA AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3548
Practice Address - Country:US
Practice Address - Phone:651-493-6658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302823101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)