Provider Demographics
NPI:1356454151
Name:FUDALA, JUDITH (LCPC)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:FUDALA
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 CASS LN
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3046
Mailing Address - Country:US
Mailing Address - Phone:847-494-6693
Mailing Address - Fax:
Practice Address - Street 1:115 N ARLINGTON HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-6075
Practice Address - Country:US
Practice Address - Phone:847-463-1055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180002603101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0081646686OtherBCBS