Provider Demographics
NPI:1922276831
Name:ROSSBACH, JUDITH EILEEN (LCSW)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:EILEEN
Last Name:ROSSBACH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:E
Other - Last Name:SHORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1011 WAIANUENUE AVE
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-2019
Mailing Address - Country:US
Mailing Address - Phone:808-969-1733
Mailing Address - Fax:
Practice Address - Street 1:31357 ONACREST DR
Practice Address - Street 2:
Practice Address - City:RUNNING SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92382
Practice Address - Country:US
Practice Address - Phone:909-645-4997
Practice Address - Fax:909-336-5751
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-13
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS182361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical