Provider Demographics
NPI:1134681679
Name:PEDERSEN, JUDITH (MS, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, BCBA, LBA
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:9302 E 22ND ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-7342
Practice Address - Country:US
Practice Address - Phone:520-278-5758
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2022-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH-000576103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-20-42492OtherBCBA CERTIFICATE