Provider Demographics
NPI:1497705750
Name:EIDELSON, JUDY IWENS (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDY
Middle Name:IWENS
Last Name:EIDELSON
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 1:413 PEMBROKE RD
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-2724
Mailing Address - Country:US
Mailing Address - Phone:610-668-4684
Mailing Address - Fax:
Practice Address - Street 1:1 BALA AVE
Practice Address - Street 2:SUITE 125
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-3212
Practice Address - Country:US
Practice Address - Phone:610-667-7137
Practice Address - Fax:610-667-7141
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-004168-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA073553Medicare PIN