1073855672 NPI number — MRS. COURTNEY LAYNE HUDDLESTON LICSW

Table of content: MRS. COURTNEY LAYNE HUDDLESTON LICSW (NPI 1073855672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073855672 NPI number — MRS. COURTNEY LAYNE HUDDLESTON LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUDDLESTON
Provider First Name:
COURTNEY
Provider Middle Name:
LAYNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HAUGSTAD
Provider Other First Name:
COURTNEY
Provider Other Middle Name:
LAYNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073855672
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 SILVER LAKE RD NW STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BRIGHTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55112-1789
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-289-5666
Provider Business Mailing Address Fax Number:
651-628-0411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
332 W SUPERIOR ST STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55802-1844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-722-4397
Provider Business Practice Location Address Fax Number:
218-722-4333
Provider Enumeration Date:
03/21/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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