Basic Information
| Provider Information | |||||||||
| NPI: | 1508181264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUDGENS | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9604 HERRIN RD | ||||||||
| Address2: | |||||||||
| City: | JOHNSTON CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629512523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189975336 | ||||||||
| FaxNumber: | 6189932969 | ||||||||
| Practice Location | |||||||||
| Address1: | 1307 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629591139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189975336 | ||||||||
| FaxNumber: | 6189932969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2010 | ||||||||
| LastUpdateDate: | 05/11/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 180.004892 | IL | Y | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | 180.004892 | IL | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 180.004892 | IL | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.