Provider Demographics
NPI:1659399236
Name:OLMSTEAD, JUDITH R (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:R
Last Name:OLMSTEAD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2024
Mailing Address - Country:US
Mailing Address - Phone:619-298-9122
Mailing Address - Fax:619-298-9122
Practice Address - Street 1:4105 1ST AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2024
Practice Address - Country:US
Practice Address - Phone:619-298-9122
Practice Address - Fax:619-298-9122
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9310103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPN0093100Medicaid
CAPN0093100Medicaid