Provider Demographics
NPI:1790016756
Name:IDE, JUDITH FLORENCE (BA, MED)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:FLORENCE
Last Name:IDE
Suffix:
Gender:F
Credentials:BA, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 S BOSTON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74119-4003
Mailing Address - Country:US
Mailing Address - Phone:918-561-6000
Mailing Address - Fax:
Practice Address - Street 1:1516 S BOSTON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74119-4003
Practice Address - Country:US
Practice Address - Phone:918-561-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-14
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health