Provider Demographics
NPI:1710385455
Name:ANDERSON, JUDITH ANN
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3971 WESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45217-1931
Mailing Address - Country:US
Mailing Address - Phone:513-368-4780
Mailing Address - Fax:
Practice Address - Street 1:5572 PRINCETON ROAD
Practice Address - Street 2:LAKOTA LOCAL SCHOOL DISTRICT
Practice Address - City:LIBERTY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45011
Practice Address - Country:US
Practice Address - Phone:513-644-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH1499917103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool