Provider Demographics
NPI:1710185764
Name:HUDSON, ANNIE WALLACE (LCSW)
Entity type:Individual
Prefix:MS
First Name:ANNIE
Middle Name:WALLACE
Last Name:HUDSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 RAND RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-2352
Mailing Address - Country:US
Mailing Address - Phone:847-699-2100
Mailing Address - Fax:847-699-2180
Practice Address - Street 1:960 RAND RD
Practice Address - Street 2:SUITE 215
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-2352
Practice Address - Country:US
Practice Address - Phone:847-699-2100
Practice Address - Fax:847-699-2180
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL11721218OtherCAQH