Provider Demographics
NPI:1487664553
Name:HART, JUDITH ANNE (LCDP)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:ANNE
Last Name:HART
Suffix:
Gender:F
Credentials:LCDP
Other - Prefix:MS
Other - First Name:JUDITH
Other - Middle Name:ANNE
Other - Last Name:LEGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCDP
Mailing Address - Street 1:163 SLATER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02861-3213
Mailing Address - Country:US
Mailing Address - Phone:401-440-0472
Mailing Address - Fax:
Practice Address - Street 1:610 WAMPANOAG TRAIL
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02915
Practice Address - Country:US
Practice Address - Phone:401-431-9870
Practice Address - Fax:401-435-7486
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILCDP00173101YA0400X
RIMHC00362101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIJL58361Medicaid