Provider Demographics
NPI:1689739963
Name:HUDSON, CYNTHIA DIANE (PT, MS, OCS)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:DIANE
Last Name:HUDSON
Suffix:
Gender:F
Credentials:PT, MS, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1742
Mailing Address - Country:US
Mailing Address - Phone:270-796-4698
Mailing Address - Fax:270-782-3274
Practice Address - Street 1:165 NATCHEZ TRACE AVE STE 200
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7947
Practice Address - Country:US
Practice Address - Phone:270-796-4698
Practice Address - Fax:270-782-3274
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY003058225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY611273988OtherFACILITY TAX ID
KY000000314785OtherANTHEM PROVIDER NUMBER
KY000000314785OtherANTHEM PROVIDER NUMBER