Provider Demographics
NPI:1750642419
Name:JUDY & BRUCE PEMBERTON, LLC
Entity Type:Organization
Organization Name:JUDY & BRUCE PEMBERTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEMBERTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:404-325-8512
Mailing Address - Street 1:1130 PIEDMONT AVE NE
Mailing Address - Street 2:SUITE 1502
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3780
Mailing Address - Country:US
Mailing Address - Phone:404-325-8512
Mailing Address - Fax:404-325-8733
Practice Address - Street 1:1145 SHERIDAN RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-3714
Practice Address - Country:US
Practice Address - Phone:404-325-8512
Practice Address - Fax:404-325-8733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001100103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBCTJMedicare UPIN