Provider Demographics
NPI:1558319749
Name:SPEVAK, JUDITH (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:
Last Name:SPEVAK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 SAINT JOHN RD
Mailing Address - Street 2:SUITE 501
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-7354
Mailing Address - Country:US
Mailing Address - Phone:219-879-0676
Mailing Address - Fax:
Practice Address - Street 1:450 SAINT JOHN RD
Practice Address - Street 2:SUITE 501
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7354
Practice Address - Country:US
Practice Address - Phone:219-879-0676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN340004521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400072852Medicare UPIN