Provider Demographics
NPI:1912425448
Name:HUDSON, WANDA DENISE (LPC)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:DENISE
Last Name:HUDSON
Suffix:
Gender:F
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:PMB #121
Mailing Address - Street 2:893 S. MAIN STREET
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-2814
Mailing Address - Country:US
Mailing Address - Phone:480-494-7799
Mailing Address - Fax:
Practice Address - Street 1:550 SUMITT AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373
Practice Address - Country:US
Practice Address - Phone:937-335-7148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1600223101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000000Medicaid