Provider Demographics
NPI:1962413567
Name:HUDSON, CLIFTON ROBERT (PHD)
Entity type:Individual
Prefix:DR
First Name:CLIFTON
Middle Name:ROBERT
Last Name:HUDSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WINDSONG WAY
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:25213-9729
Mailing Address - Country:US
Mailing Address - Phone:304-415-2299
Mailing Address - Fax:800-983-2875
Practice Address - Street 1:515 3RD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1329
Practice Address - Country:US
Practice Address - Phone:304-415-2299
Practice Address - Fax:800-983-2875
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2012-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV908103T00000X, 103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810002673Medicaid
HUC31212Medicare ID - Type Unspecified