Provider Demographics
NPI:1245904788
Name:CHUDZINSKI, KYLE JOHN (MA, LAC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:JOHN
Last Name:CHUDZINSKI
Suffix:
Gender:M
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 SUSSEX AVE
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-3721
Mailing Address - Country:US
Mailing Address - Phone:609-405-9158
Mailing Address - Fax:
Practice Address - Street 1:221 LAUREL RD
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-2330
Practice Address - Country:US
Practice Address - Phone:856-772-5809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-08
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC01025900101YP2500X
NJ37AC00579300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional