Healthcare Provider Details

I. General information

NPI: 1710582853
Provider Name (Legal Business Name): MARY ELIZABETH HUDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY ELIZABETH HIGH

II. Dates (important events)

Enumeration Date: 12/04/2020
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12429 SCOFIELD FARMS DR
AUSTIN TX
78758-2640
US

IV. Provider business mailing address

4341 CANYON GLEN CIR
AUSTIN TX
78732-2187
US

V. Phone/Fax

Practice location:
  • Phone: 512-835-9080
  • Fax:
Mailing address:
  • Phone: 409-370-9768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number116480
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: