Provider Demographics
NPI:1164542254
Name:MCCOWN, JUDY A (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDY
Middle Name:A
Last Name:MCCOWN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22811 GREATER MACK AVE
Mailing Address - Street 2:SUITE L-3
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2021
Mailing Address - Country:US
Mailing Address - Phone:586-777-3988
Mailing Address - Fax:
Practice Address - Street 1:22811 GREATER MACK AVE
Practice Address - Street 2:SUITE L-3
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2021
Practice Address - Country:US
Practice Address - Phone:586-777-3988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008870103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301008870OtherPSYCHOLOGIST LICENSE
MI680EO45650OtherBLUE CROSS BLUE SHIELD
MI6301008870OtherPSYCHOLOGIST LICENSE