Provider Demographics
NPI:1740788868
Name:HUDSON, DAVID LYLE (LMSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LYLE
Last Name:HUDSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6119 N 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-1511
Mailing Address - Country:US
Mailing Address - Phone:623-210-3961
Mailing Address - Fax:
Practice Address - Street 1:6119 N 32ND AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-1511
Practice Address - Country:US
Practice Address - Phone:623-210-3961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12598104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker