Provider Demographics
NPI:1225152648
Name:GOEDEKE, JUDITH PATRICIA (MAC LAC)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:PATRICIA
Last Name:GOEDEKE
Suffix:
Gender:F
Credentials:MAC LAC
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:
Other - Last Name:SNYDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10544 PATUXENT RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723
Mailing Address - Country:US
Mailing Address - Phone:301-776-3158
Mailing Address - Fax:
Practice Address - Street 1:10544 PATUXENT RIDGE WAY
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723
Practice Address - Country:US
Practice Address - Phone:301-776-3158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU00813171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
BL93JPOtherMD BCBS