Provider Demographics
NPI:1235217290
Name:HUDGENS, LISA LONG (MA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LONG
Last Name:HUDGENS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 GINN ALTMAN AVE STE C
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:SC
Mailing Address - Zip Code:29924-3963
Mailing Address - Country:US
Mailing Address - Phone:803-943-2800
Mailing Address - Fax:
Practice Address - Street 1:NEW LIFE CENTER
Practice Address - Street 2:102 GINN ALTMAN AVE, STE C
Practice Address - City:HAMPTON
Practice Address - State:SC
Practice Address - Zip Code:29924
Practice Address - Country:US
Practice Address - Phone:803-943-8175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC190166Medicaid