Provider Demographics
NPI:1407191240
Name:NEDRY, JULIA (LICSW)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:NEDRY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 GUNN RD EXT APT C
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01073-9648
Mailing Address - Country:US
Mailing Address - Phone:714-318-9235
Mailing Address - Fax:
Practice Address - Street 1:17 GUNN RD EXT APT C
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01073-9648
Practice Address - Country:US
Practice Address - Phone:714-318-9235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW02259104100000X
MA1171321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker