Provider Demographics
NPI:1790189264
Name:HUDIMAC, MICHELLE MARIE (MED)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:HUDIMAC
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3785 MAPLE GROVE CT
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-8618
Mailing Address - Country:US
Mailing Address - Phone:814-288-9648
Mailing Address - Fax:
Practice Address - Street 1:201 THORNBERRY BRANCH LN
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32124-3652
Practice Address - Country:US
Practice Address - Phone:386-872-4892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-13
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician