Basic Information
| Provider Information | |||||||||
| NPI: | 1932404035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUDSON | ||||||||
| FirstName: | KRISTEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424204855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708274652 | ||||||||
| FaxNumber: | 2708311182 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424204855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708274652 | ||||||||
| FaxNumber: | 2708311182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2011 | ||||||||
| LastUpdateDate: | 11/05/2013 | ||||||||
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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 | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 1000 | KY | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 7100215710 | 05 | KY | MEDICAID | 7100174590 | 01 | KY | SCL WAIVER | OTHER |