Healthcare Provider Details

I. General information

NPI: 1295269553
Provider Name (Legal Business Name): GLORIA HUDNELL LICDC-CS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 C CT
ASHTABULA OH
44004-4577
US

IV. Provider business mailing address

2801 C COURT
ASHTABULA OHIO
44004
UM

V. Phone/Fax

Practice location:
  • Phone: 440-998-0722
  • Fax: 440-992-1699
Mailing address:
  • Phone: 440-998-0722
  • Fax: 440-992-1699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number975953
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: