Provider Demographics
NPI:1568841401
Name:JUDAH, MICHAELA
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:JUDAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 SE JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-2025
Mailing Address - Country:US
Mailing Address - Phone:541-971-6841
Mailing Address - Fax:
Practice Address - Street 1:1650 SW 45TH PL
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-1768
Practice Address - Country:US
Practice Address - Phone:541-757-8068
Practice Address - Fax:541-758-1030
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORT1759106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health