Provider Demographics
NPI:1558420679
Name:STICKLES, JUDITH LEE (MA CCCSLP)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:LEE
Last Name:STICKLES
Suffix:
Gender:F
Credentials:MA CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 LEXINGTON ROAD
Mailing Address - Street 2:
Mailing Address - City:ORONO
Mailing Address - State:ME
Mailing Address - Zip Code:04473-3665
Mailing Address - Country:US
Mailing Address - Phone:207-866-3427
Mailing Address - Fax:207-581-2060
Practice Address - Street 1:5724 DUNN HALL
Practice Address - Street 2:ROOM 336 UNIVERSITY OF MAINE
Practice Address - City:ORONO
Practice Address - State:ME
Practice Address - Zip Code:04469-5724
Practice Address - Country:US
Practice Address - Phone:207-581-2259
Practice Address - Fax:207-581-2060
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP453235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME027996OtherANTHEM BCBS