Provider Demographics
NPI:1487653465
Name:PEELLE, JUDITH ANNE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:ANNE
Last Name:PEELLE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3855 FOREST TRL
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-9465
Mailing Address - Country:US
Mailing Address - Phone:269-355-6089
Mailing Address - Fax:
Practice Address - Street 1:3855 FOREST TRL
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-9465
Practice Address - Country:US
Practice Address - Phone:269-355-6089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010683791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI068379OtherSTATE LICENSE
MIP39040021Medicare PIN