Provider Demographics
NPI:1164474219
Name:GOLDEN, JUDITH LEERS (LICSW, LCSW)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:LEERS
Last Name:GOLDEN
Suffix:
Gender:F
Credentials:LICSW, LCSW
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:ELLEN
Other - Last Name:LEERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW, LCSW
Mailing Address - Street 1:PO BOX 1530
Mailing Address - Street 2:
Mailing Address - City:VINEYARD HAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02568-0907
Mailing Address - Country:US
Mailing Address - Phone:914-391-9123
Mailing Address - Fax:
Practice Address - Street 1:62 MAIN ST.
Practice Address - Street 2:
Practice Address - City:VINEYARD HAVEN
Practice Address - State:MA
Practice Address - Zip Code:02568
Practice Address - Country:US
Practice Address - Phone:914-391-9123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0717801041C0700X
MA1152911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY071780OtherNYS LCSW LICENSE #
NY071780OtherNYS LCSW LICENSE #
MA0015219Medicare UPIN