Basic Information
| Provider Information | |||||||||
| NPI: | 1487722062 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUDSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | GRADEN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | MA, PLMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 LAFAYETTE DR | ||||||||
| Address2: | |||||||||
| City: | PAPILLION | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680462911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023447000 | ||||||||
| FaxNumber: | 4023448089 | ||||||||
| Practice Location | |||||||||
| Address1: | 1941 S 42ND ST | ||||||||
| Address2: | SUITE 538 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681052939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023447000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 8192 | NE | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 815866000020974 | 05 | NE | MEDICAID |