Provider Demographics
NPI:1265769897
Name:CORDOVANO, JUDAH D (LCSW)
Entity type:Individual
Prefix:MS
First Name:JUDAH
Middle Name:D
Last Name:CORDOVANO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 NW OGEOHEE ST
Mailing Address - Street 2:
Mailing Address - City:MICANOPY
Mailing Address - State:FL
Mailing Address - Zip Code:32667-4145
Mailing Address - Country:US
Mailing Address - Phone:352-262-2035
Mailing Address - Fax:
Practice Address - Street 1:408 W UNIVERSITY AVE
Practice Address - Street 2:SUITE 600A
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-3248
Practice Address - Country:US
Practice Address - Phone:352-262-2035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-03
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW8973104100000X
FLSW 89731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDO093AMedicare PIN