Provider Demographics
NPI:1073991675
Name:MACDONALD, JUDITH
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 W APACHE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5835
Mailing Address - Country:US
Mailing Address - Phone:505-325-5321
Mailing Address - Fax:505-325-6453
Practice Address - Street 1:313 W APACHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5835
Practice Address - Country:US
Practice Address - Phone:505-325-5321
Practice Address - Fax:505-325-6453
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLPCC 2948101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1902014350OtherNPI