Healthcare Provider Details

I. General information

NPI: 1205169968
Provider Name (Legal Business Name): JOHN B HUDOME INNOVATIVE CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 09/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E MAIN ST
MAPLE SHADE NJ
08052-2621
US

IV. Provider business mailing address

105 E MAIN ST
MAPLE SHADE NJ
08052-2621
US

V. Phone/Fax

Practice location:
  • Phone: 856-438-5256
  • Fax:
Mailing address:
  • Phone: 856-438-5256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number44SC01389300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number44SC01389300
License Number StateNJ

VIII. Authorized Official

Name: DR. JOHN B HUDOME
Title or Position: OWNER
Credential: DCH, LCSW
Phone: 856-438-5256