Provider Demographics
NPI:1356744551
Name:PUDWILL, CHRISTOPHER (CSW)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:PUDWILL
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5045
Mailing Address - Street 2:ATTN: PFS PROV ENRLLMT
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5045
Mailing Address - Country:US
Mailing Address - Phone:605-322-4079
Mailing Address - Fax:
Practice Address - Street 1:2412 S CLIFF AVE
Practice Address - Street 2:STE 200
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-4031
Practice Address - Country:US
Practice Address - Phone:605-322-4079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-01
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD33441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS108907Medicare PIN