Provider Demographics
NPI:1437148426
Name:DERRISO, JUDITH LOUDON (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:LOUDON
Last Name:DERRISO
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 1:1835 SAVOY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1072
Mailing Address - Country:US
Mailing Address - Phone:770-495-3396
Mailing Address - Fax:770-495-2307
Practice Address - Street 1:308 COLISEUM DR
Practice Address - Street 2:SUITE 120
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3865
Practice Address - Country:US
Practice Address - Phone:478-745-6130
Practice Address - Fax:478-745-4443
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBGPFMedicare PIN
GAP00628241Medicare PIN