Provider Demographics
NPI:1639643802
Name:PRUDOM, JULIE ANN (LPC)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
Last Name:PRUDOM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 W WAYFARER CT
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-6865
Mailing Address - Country:US
Mailing Address - Phone:920-851-4041
Mailing Address - Fax:
Practice Address - Street 1:524 W WAYFARER CT
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-6865
Practice Address - Country:US
Practice Address - Phone:920-851-4041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1767-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional