Provider Demographics
NPI:1386151256
Name:KOENITZ-HUDAC, ANITA
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:KOENITZ-HUDAC
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 1:929 EDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-4623
Mailing Address - Country:US
Mailing Address - Phone:224-765-3214
Mailing Address - Fax:
Practice Address - Street 1:929 EDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-4623
Practice Address - Country:US
Practice Address - Phone:224-765-3214
Practice Address - Fax:224-765-3214
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL16213556Medicaid