Provider Demographics
NPI:1609002625
Name:HART-BERMEA, JUDY ANNETTE (TLLP)
Entity Type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:ANNETTE
Last Name:HART-BERMEA
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 W FORT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48216-1652
Mailing Address - Country:US
Mailing Address - Phone:313-841-7380
Mailing Address - Fax:313-841-3730
Practice Address - Street 1:3815 W FORT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48216-1652
Practice Address - Country:US
Practice Address - Phone:313-841-7380
Practice Address - Fax:313-841-3730
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013755103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist