Provider Demographics
NPI:1326031774
Name:JUDGE, DANIEL JOSEPH (MA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOSEPH
Last Name:JUDGE
Suffix:
Gender:M
Credentials:MA
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 272
Mailing Address - Street 2:
Mailing Address - City:SEVERANCE
Mailing Address - State:CO
Mailing Address - Zip Code:80546-0272
Mailing Address - Country:US
Mailing Address - Phone:970-214-0668
Mailing Address - Fax:
Practice Address - Street 1:1912 CAPITOL AVE
Practice Address - Street 2:STE 305
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3650
Practice Address - Country:US
Practice Address - Phone:970-214-0668
Practice Address - Fax:307-634-6943
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC866101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional