Provider Demographics
NPI:1659421493
Name:PEASE, JUDY G (MAPC, LISAC)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:G
Last Name:PEASE
Suffix:
Gender:F
Credentials:MAPC, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85147-0001
Mailing Address - Country:US
Mailing Address - Phone:602-528-1200
Mailing Address - Fax:602-528-1374
Practice Address - Street 1:483 W. SEED FARM RD
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85147
Practice Address - Country:US
Practice Address - Phone:602-528-1200
Practice Address - Fax:602-528-1374
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC 11635101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ166182Medicaid