Provider Demographics
NPI:1558472837
Name:WIGHTMAN MCQUADE, JUDITH (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:
Last Name:WIGHTMAN MCQUADE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JUDITH
Other - Middle Name:M
Other - Last Name:WIGHTMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 60284
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-0284
Mailing Address - Country:US
Mailing Address - Phone:508-753-2389
Mailing Address - Fax:508-753-1685
Practice Address - Street 1:20 PARK AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3911
Practice Address - Country:US
Practice Address - Phone:508-753-2389
Practice Address - Fax:508-753-1785
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6291103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05020Medicare ID - Type Unspecified