Healthcare Provider Details

I. General information

NPI: 1568288504
Provider Name (Legal Business Name): TRINA ANNE HUDSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 11/25/2024
Certification Date: 11/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 REDWOOD DR
NEW BLOOMFIELD MO
65063-5423
US

IV. Provider business mailing address

621 REDWOOD DR
NEW BLOOMFIELD MO
65063-5423
US

V. Phone/Fax

Practice location:
  • Phone: 573-619-6492
  • Fax:
Mailing address:
  • Phone: 573-619-6492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2023038155
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: