Provider Demographics
NPI:1366888737
Name:HUDSPETH, CARROL ANN
Entity type:Individual
Prefix:
First Name:CARROL
Middle Name:ANN
Last Name:HUDSPETH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1337
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MS
Mailing Address - Zip Code:39654-1337
Mailing Address - Country:US
Mailing Address - Phone:601-587-9226
Mailing Address - Fax:
Practice Address - Street 1:1134 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MS
Practice Address - Zip Code:39654-7681
Practice Address - Country:US
Practice Address - Phone:601-587-9226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS251QA0600X103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07684032Medicaid