Provider Demographics
NPI:1356860571
Name:JUDSON UNIVERSITY
Entity Type:Organization
Organization Name:JUDSON UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:DIDOMINICIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:847-628-2464
Mailing Address - Street 1:1151 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-1404
Mailing Address - Country:US
Mailing Address - Phone:847-628-2464
Mailing Address - Fax:847-628-2044
Practice Address - Street 1:1151 N STATE ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-1404
Practice Address - Country:US
Practice Address - Phone:847-628-2464
Practice Address - Fax:847-628-2044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE