Provider Demographics
NPI:1508848391
Name:WILLIAMS, JUDITH L (PSYD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:L
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 289
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:OH
Mailing Address - Zip Code:43517-0289
Mailing Address - Country:US
Mailing Address - Phone:260-925-2017
Mailing Address - Fax:260-925-9713
Practice Address - Street 1:2355 E CEDAR CANYONS RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-9330
Practice Address - Country:US
Practice Address - Phone:260-925-2017
Practice Address - Fax:260-925-9713
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000462101YM0800X
IN20042458A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health