Provider Demographics
NPI:1003195082
Name:AGUSTIN, JUDITH LOUISE ROSS (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:LOUISE ROSS
Last Name:AGUSTIN
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 PENN AVE S STE 150H
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-1346
Mailing Address - Country:US
Mailing Address - Phone:612-314-6012
Mailing Address - Fax:
Practice Address - Street 1:8100 PENN AVE S STE 150H
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1346
Practice Address - Country:US
Practice Address - Phone:612-314-6012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT2659106H00000X
MN2534106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1528451028OtherGROUP/BUSINESS ENTITY