Provider Demographics
NPI:1346485810
Name:PROFANT, JUDITH RUTH (PHD, CBSM)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:RUTH
Last Name:PROFANT
Suffix:
Gender:F
Credentials:PHD, CBSM
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 727
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-0727
Mailing Address - Country:US
Mailing Address - Phone:949-302-2020
Mailing Address - Fax:
Practice Address - Street 1:5001 BIRCH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2116
Practice Address - Country:US
Practice Address - Phone:949-302-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20784103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical