Provider Demographics
NPI:1356313530
Name:KLINE, JUDITH A (LCSW)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:KLINE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:812-337-2438
Practice Address - Street 1:91 W MOUND ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:IN
Practice Address - Zip Code:47448-7049
Practice Address - Country:US
Practice Address - Phone:812-988-2258
Practice Address - Fax:812-988-2257
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000138A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000339603OtherANTHEM PIN
IN143230SSMedicare ID - Type Unspecified