Provider Demographics
NPI:1679761399
Name:JUDY, DAVID (LCPC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:JUDY
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 MICAH DRIVE
Mailing Address - Street 2:PO DRAWER M
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-0913
Mailing Address - Country:US
Mailing Address - Phone:618-395-4306
Mailing Address - Fax:618-395-4507
Practice Address - Street 1:504 MICAH DRIVE
Practice Address - Street 2:DRAWER M
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-0913
Practice Address - Country:US
Practice Address - Phone:618-395-4306
Practice Address - Fax:618-395-4507
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004995101YM0800X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180004995OtherLCPC