Provider Demographics
NPI:1508928383
Name:VAN DER WENDE, JUDY (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDY
Middle Name:
Last Name:VAN DER WENDE
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 1:3695 ALAMO ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2188
Mailing Address - Country:US
Mailing Address - Phone:805-407-4730
Mailing Address - Fax:805-581-0889
Practice Address - Street 1:3695 ALAMO ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-2188
Practice Address - Country:US
Practice Address - Phone:805-407-4730
Practice Address - Fax:805-581-0889
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18757103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ62945Medicare UPIN