Provider Demographics
NPI:1902658990
Name:HUDDLESTON, LILLIE BEATRICE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LILLIE
Middle Name:BEATRICE
Last Name:HUDDLESTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 MEMORIAL DR SE STE 422
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-1537
Mailing Address - Country:US
Mailing Address - Phone:404-574-0103
Mailing Address - Fax:
Practice Address - Street 1:945 MEMORIAL DR SE STE 422
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-1537
Practice Address - Country:US
Practice Address - Phone:404-574-0103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003967103TM1800X, 103TS0200X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool