Provider Demographics
NPI:1508628389
Name:JUDGE-PONSTEIN, AUDREY MARIE
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:MARIE
Last Name:JUDGE-PONSTEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 E MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-1736
Mailing Address - Country:US
Mailing Address - Phone:616-900-5001
Mailing Address - Fax:616-333-8020
Practice Address - Street 1:6269 WILMINGTON DR
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-7890
Practice Address - Country:US
Practice Address - Phone:231-402-1306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician