Provider Demographics
NPI:1922287812
Name:CAIN, JUDITH K (PSYD)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:K
Last Name:CAIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806-2607
Mailing Address - Country:US
Mailing Address - Phone:417-863-0021
Mailing Address - Fax:417-863-0021
Practice Address - Street 1:1150 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-2607
Practice Address - Country:US
Practice Address - Phone:417-863-0021
Practice Address - Fax:417-863-0021
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002011100103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499035616Medicaid
MO217270080Medicare PIN
MO499035616Medicaid