Provider Demographics
NPI:1689784647
Name:PHEATT, JUDITH MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:MARIE
Last Name:PHEATT
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 1:3432 COREY RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-1651
Mailing Address - Country:US
Mailing Address - Phone:419-843-5358
Mailing Address - Fax:419-534-2397
Practice Address - Street 1:3454 OAK ALLEY CT
Practice Address - Street 2:305
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1306
Practice Address - Country:US
Practice Address - Phone:419-534-2468
Practice Address - Fax:419-534-2397
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5138103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCP19472Medicare ID - Type Unspecified