Provider Demographics
NPI:1710912308
Name:ANDERSON, JUDITH (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:
Last Name:ANDERSON
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 1:675 N 36TH ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4475
Mailing Address - Country:US
Mailing Address - Phone:765-447-7146
Mailing Address - Fax:765-447-4932
Practice Address - Street 1:675 N 36TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4475
Practice Address - Country:US
Practice Address - Phone:765-447-7146
Practice Address - Fax:765-447-4932
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010444103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical