Provider Demographics
NPI:1821113895
Name:JUDD, BRETT M (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BRETT
Middle Name:M
Last Name:JUDD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 WILSON AVE STE 3A
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5046
Mailing Address - Country:US
Mailing Address - Phone:208-904-3225
Mailing Address - Fax:208-904-3227
Practice Address - Street 1:611 WILSON AVE STE 3A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5046
Practice Address - Country:US
Practice Address - Phone:208-904-3225
Practice Address - Fax:208-904-3227
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-27751104100000X
246ZE0500X
IDLCSW-386011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEG