Provider Demographics
NPI:1427198217
Name:PEMBERTON, JUDY S (PHD)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:S
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 PIEDMONT AVE NE
Mailing Address - Street 2:#1502
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3780
Mailing Address - Country:US
Mailing Address - Phone:404-325-8512
Mailing Address - Fax:404-325-8733
Practice Address - Street 1:1145 SHERIDAN RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-3714
Practice Address - Country:US
Practice Address - Phone:404-325-8512
Practice Address - Fax:404-325-8733
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001100103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBCTJMedicare UPIN