Provider Demographics
NPI:1780634865
Name:EDWARDS, JUDITH (LICSW)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-8885
Mailing Address - Country:US
Mailing Address - Phone:802-885-1088
Mailing Address - Fax:
Practice Address - Street 1:56 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-2963
Practice Address - Country:US
Practice Address - Phone:802-376-5930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-0000834101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT080-58147OtherBLUE CROSS/BLUE SHIELD
VT1008052Medicaid
VTVN2753Medicare ID - Type Unspecified