Provider Demographics
NPI:1295048817
Name:HUDSON-DAVIS, VIVIAN DIANE (DEVELOPMENTAL THERAP)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:DIANE
Last Name:HUDSON-DAVIS
Suffix:
Gender:F
Credentials:DEVELOPMENTAL THERAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 S DANTE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60425-2058
Mailing Address - Country:US
Mailing Address - Phone:708-757-3560
Mailing Address - Fax:708-757-4799
Practice Address - Street 1:242 S DANTE AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IL
Practice Address - Zip Code:60425-2058
Practice Address - Country:US
Practice Address - Phone:708-757-3560
Practice Address - Fax:708-757-4799
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-24
Last Update Date:2010-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1972388222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist