Provider Demographics
NPI:1407504814
Name:JUDGE, MADONNA RAE (LLPC)
Entity Type:Individual
Prefix:
First Name:MADONNA
Middle Name:RAE
Last Name:JUDGE
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 HUTTON ST APT 4
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1246
Mailing Address - Country:US
Mailing Address - Phone:313-820-0626
Mailing Address - Fax:
Practice Address - Street 1:9409 N HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4696
Practice Address - Country:US
Practice Address - Phone:734-559-3540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-15
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451019574101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health