Provider Demographics
NPI:1093154049
Name:SIMON, JUDY CORINNE (BCBA)
Entity Type:Individual
Prefix:MS
First Name:JUDY
Middle Name:CORINNE
Last Name:SIMON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9878 EL DORADO WAY
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-9510
Mailing Address - Country:US
Mailing Address - Phone:707-272-1457
Mailing Address - Fax:
Practice Address - Street 1:1014 WALNUT ST APT C
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-4978
Practice Address - Country:US
Practice Address - Phone:707-272-1457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-01-0719103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst