Provider Demographics
NPI:1245846252
Name:GILL, JUDALYN EVETTE (SUDPT, AAC, CPC)
Entity type:Individual
Prefix:
First Name:JUDALYN
Middle Name:EVETTE
Last Name:GILL
Suffix:
Gender:F
Credentials:SUDPT, AAC, CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 59
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:506 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-3517
Practice Address - Country:US
Practice Address - Phone:360-427-5232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61040187101YA0400X
WACG61424783175T00000X
WACO61040187101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2164976Medicaid