Provider Demographics
NPI:1891572970
Name:ANDERSON, CHUDNEY LATISHA
Entity Type:Individual
Prefix:
First Name:CHUDNEY
Middle Name:LATISHA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16212 ROCKFORD SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:HURT
Mailing Address - State:VA
Mailing Address - Zip Code:24563-2708
Mailing Address - Country:US
Mailing Address - Phone:434-856-2893
Mailing Address - Fax:
Practice Address - Street 1:16212 ROCKFORD SCHOOL ROAD
Practice Address - Street 2:
Practice Address - City:HURT
Practice Address - State:VA
Practice Address - Zip Code:24563-2708
Practice Address - Country:US
Practice Address - Phone:434-856-2893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA8561-08-011320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities