MEDICARE: CLIFTON R. HUDSON, PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	908	WV
2	103TC0700X	Clinical Psychologist	908	WV
3	103TF0200X	Forensic Psychologist	908	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194261123
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLIFTON R. HUDSON, PH.D.

Provider Business Mailing Address
First Line	:	1335 VIRGINIA ST E
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25301-3011
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1335 VIRGINIA ST E
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25301-3011
Country	:	US
Telephone Number	:	800-983-2875
Fax Number	:

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	DR. CLIFTON ROBERT HUDSON
Credential	:	PH.D.
Telephone Number	:	800-983-2875

Provider Enumeration Date	:	01/14/2017
Last Update Date	:	01/14/2017

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