Provider Demographics
NPI:1295782175
Name:PROCHASKA, JUDY H (MSW)
Entity type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:H
Last Name:PROCHASKA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807
Mailing Address - Country:US
Mailing Address - Phone:563-359-4049
Mailing Address - Fax:563-359-4069
Practice Address - Street 1:2101 E 38TH ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807
Practice Address - Country:US
Practice Address - Phone:563-359-4049
Practice Address - Fax:563-359-4069
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA011601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1108750000Medicaid
IA1108750000Medicaid
IAI15641Medicare ID - Type Unspecified