Provider Demographics
NPI:1649602269
Name:HUDSON, CHANIQUA LACHELL (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CHANIQUA
Middle Name:LACHELL
Last Name:HUDSON
Suffix:
Gender:F
Credentials:MED, 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:PO BOX 348
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-0009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:345 MOOSE LODGE RD
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-3903
Practice Address - Country:US
Practice Address - Phone:229-854-6158
Practice Address - Fax:678-572-4604
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006261235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist