Provider Demographics
NPI:1740789254
Name:KWAK, JUDY
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:KWAK
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:PO BOX 46
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CA
Mailing Address - Zip Code:91021-0046
Mailing Address - Country:US
Mailing Address - Phone:917-907-4833
Mailing Address - Fax:
Practice Address - Street 1:3650 LOS FELIZ BLVD APT 32
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-2431
Practice Address - Country:US
Practice Address - Phone:917-907-4833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-10
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-2962235Z00000X
CA28106235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist