Provider Demographics
NPI:1407815723
Name:STOGDELL, JUDITH ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:STOGDELL
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 1:1601 HOME AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:IL
Mailing Address - Zip Code:62656-3075
Mailing Address - Country:US
Mailing Address - Phone:217-737-9959
Mailing Address - Fax:847-447-0197
Practice Address - Street 1:523 N ELM ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-1524
Practice Address - Country:US
Practice Address - Phone:217-737-9959
Practice Address - Fax:847-774-4701
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490097001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL282384OtherTRICARE
IL282384OtherTRICARE