Provider Demographics
NPI:1154485902
Name:JUDGE, KELLY (LSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JUDGE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:OH
Mailing Address - Zip Code:43357-0817
Mailing Address - Country:US
Mailing Address - Phone:937-642-1254
Mailing Address - Fax:937-642-2806
Practice Address - Street 1:131 N MAIN
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040
Practice Address - Country:US
Practice Address - Phone:937-642-1254
Practice Address - Fax:937-642-2806
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0026249104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker