Provider Demographics
NPI:1972773646
Name:HUDDLESTON, ISAAC DONNELL (LPC)
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:DONNELL
Last Name:HUDDLESTON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:392 CHEZ PAREE DR
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-3539
Mailing Address - Country:US
Mailing Address - Phone:314-833-7080
Mailing Address - Fax:
Practice Address - Street 1:392 CHEZ PAREE DR
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-3539
Practice Address - Country:US
Practice Address - Phone:314-833-7080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-09
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008004281101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494055700Medicaid