Healthcare Provider Details

I. General information

NPI: 1295073971
Provider Name (Legal Business Name): COURTNEY BLAKE HUDSON MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2013
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 OVERHILL DR STE 105
MOORESVILLE NC
28117-8232
US

IV. Provider business mailing address

125 OVERHILL DR STE 105
MOORESVILLE NC
28117-8232
US

V. Phone/Fax

Practice location:
  • Phone: 704-651-5124
  • Fax: 704-799-8949
Mailing address:
  • Phone: 704-651-5124
  • Fax: 704-799-8949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC009446
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP007161
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: