Provider Demographics
NPI:1922087113
Name:HUDDLESTON, DAVID (LICSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:HUDDLESTON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3601
Mailing Address - Country:US
Mailing Address - Phone:617-562-5550
Mailing Address - Fax:617-562-5564
Practice Address - Street 1:77 WARREN ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3601
Practice Address - Country:US
Practice Address - Phone:617-562-5550
Practice Address - Fax:617-562-5564
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA111001104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP23070Medicare ID - Type Unspecified