Provider Demographics
NPI:1720205776
Name:HUDSON, MARY ANN (MEDCCCSLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:HUDSON
Suffix:
Gender:F
Credentials:MEDCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 13TH ST
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-5038
Mailing Address - Country:US
Mailing Address - Phone:334-448-5636
Mailing Address - Fax:334-448-5637
Practice Address - Street 1:703 13TH ST
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-5038
Practice Address - Country:US
Practice Address - Phone:334-448-5636
Practice Address - Fax:334-448-5637
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2982235Z00000X
GA007232235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1265764500Medicaid
AL129089Medicaid