Provider Demographics
NPI:1659672665
Name:JUDSON, DOUGLASS (MSW)
Entity Type:Individual
Prefix:MR
First Name:DOUGLASS
Middle Name:
Last Name:JUDSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1737 WARWICK RD SE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4527
Mailing Address - Country:US
Mailing Address - Phone:617-962-1794
Mailing Address - Fax:
Practice Address - Street 1:201 SHELDON BLVD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4513
Practice Address - Country:US
Practice Address - Phone:616-459-0255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-07
Last Update Date:2010-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010909611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical