Provider Demographics
NPI:1841211315
Name:JUDGE, DAVERNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DAVERNE
Middle Name:
Last Name:JUDGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:DAVERNE
Other - Middle Name:
Other - Last Name:DARITY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30 HARRIMAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924
Mailing Address - Country:US
Mailing Address - Phone:845-291-2600
Mailing Address - Fax:845-291-2628
Practice Address - Street 1:141 PIKE STREET
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771
Practice Address - Country:US
Practice Address - Phone:845-858-1456
Practice Address - Fax:845-858-1459
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY073380-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
N62881Medicare UPIN