Provider Demographics
NPI:1821034851
Name:SMITH-DANDRIDGE, JUDY L (LCSW)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:L
Last Name:SMITH-DANDRIDGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:JUDY
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, LADC
Mailing Address - Street 1:601 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-5335
Mailing Address - Country:US
Mailing Address - Phone:479-236-9539
Mailing Address - Fax:
Practice Address - Street 1:601 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-5335
Practice Address - Country:US
Practice Address - Phone:479-236-9539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT05229104100000X
AR2204-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004225901Medicaid
CT800003608Medicare ID - Type Unspecified
CT004225901Medicaid
AR5V100Medicare PIN