Basic Information
| Provider Information | |||||||||
| NPI: | 1518458124 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUDSON | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4644 | ||||||||
| Address2: | |||||||||
| City: | BLUE JAY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923174644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093383222 | ||||||||
| FaxNumber: | 9093383221 | ||||||||
| Practice Location | |||||||||
| Address1: | 24028 LAKE DR | ||||||||
| Address2: | |||||||||
| City: | CRESTLINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093383222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2018 | ||||||||
| LastUpdateDate: | 05/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | APCC4814 | CA | N | Behavioral Health & Social Service Providers | Counselor | Professional | 106H00000X | AMFT104636 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.