Provider Demographics
NPI:1962709071
Name:HUDDLESTON, DOREEN DANICE (MSW)
Entity type:Individual
Prefix:
First Name:DOREEN
Middle Name:DANICE
Last Name:HUDDLESTON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 941
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:IN
Mailing Address - Zip Code:46507-0941
Mailing Address - Country:US
Mailing Address - Phone:574-286-0030
Mailing Address - Fax:574-848-9571
Practice Address - Street 1:928 EAST WAYNE ST
Practice Address - Street 2:SUIT C
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617
Practice Address - Country:US
Practice Address - Phone:574-286-0030
Practice Address - Fax:574-848-9571
Is Sole Proprietor?:No
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200528060AMedicaid