Healthcare Provider Details

I. General information

NPI: 1083381495
Provider Name (Legal Business Name): MS. ALLIE MARIE HUDDLESTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 E WASHINGTON ST STE 2D
BLOOMINGTON IL
61701-4365
US

IV. Provider business mailing address

3506 GABBY DR
BLOOMINGTON IL
61704-8684
US

V. Phone/Fax

Practice location:
  • Phone: 309-822-2261
  • Fax:
Mailing address:
  • Phone: 309-533-8486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number178.018526
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: