Provider Demographics
NPI:1477394559
Name:HUDSON, KAMBRIELLE ALISSA (MSW)
Entity type:Individual
Prefix:MISS
First Name:KAMBRIELLE
Middle Name:ALISSA
Last Name:HUDSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 N 725 W
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-5341
Mailing Address - Country:US
Mailing Address - Phone:208-516-6108
Mailing Address - Fax:
Practice Address - Street 1:3501 W ELDER ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-4986
Practice Address - Country:US
Practice Address - Phone:208-286-1529
Practice Address - Fax:208-445-2285
Is Sole Proprietor?:No
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-45247101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health