MEDICARE: DIANE KAY HUDSON PH.D., BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1	OTHER		A

General Provider Information

NPI Number	:	1629319272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE KAY HUDSON PH.D., BCBA

Provider Business Mailing Address
First Line	:	PO BOX 2653
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-2653
Country	:	US
Telephone Number	:	801-251-6219
Fax Number	:

Provider Business Practice Location Address
First Line	:	310 E BROADWAY AVE STE 8
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-8636
Country	:	US
Telephone Number	:	801-251-6219
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2013
Last Update Date	:	02/09/2023

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