Provider Demographics
NPI:1932176278
Name:HUDDLESTON, CAROLYN LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:LEE
Last Name:HUDDLESTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:CAROLYN
Other - Middle Name:LEE
Other - Last Name:FRAPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:316 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67901
Mailing Address - Country:US
Mailing Address - Phone:620-626-4508
Mailing Address - Fax:620-626-4508
Practice Address - Street 1:316 W 7TH ST
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901
Practice Address - Country:US
Practice Address - Phone:620-626-4508
Practice Address - Fax:620-626-4508
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLP598103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS004471OtherBLUE CROSS BLUE SHIELD
OK100842710AMedicaid
KS100238670AMedicaid
004471Medicare ID - Type Unspecified
KS100238670AMedicaid