Provider Demographics
NPI:1922149905
Name:UDELF, DAVID JAMES (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JAMES
Last Name:UDELF
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23360 CHAGRIN BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5547
Mailing Address - Country:US
Mailing Address - Phone:216-595-3175
Mailing Address - Fax:216-595-3178
Practice Address - Street 1:23360 CHAGRIN BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5547
Practice Address - Country:US
Practice Address - Phone:216-595-3175
Practice Address - Fax:216-595-3178
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2011-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4149103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0115806Medicaid
OH0115806Medicaid