Provider Demographics
NPI:1851434484
Name:PAW, JUDY (MA)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:PAW
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24876 TAYLOR STREET
Mailing Address - Street 2:LOMA LINDA
Mailing Address - City:CALIFORNIA
Mailing Address - State:CA
Mailing Address - Zip Code:92350
Mailing Address - Country:US
Mailing Address - Phone:909-557-5555
Mailing Address - Fax:
Practice Address - Street 1:11092 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1706
Practice Address - Country:US
Practice Address - Phone:909-557-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88169106H00000X
CA9856124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist