Provider Demographics
NPI:1336351261
Name:ASHWORTH, JUDITH SUSAN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:SUSAN
Last Name:ASHWORTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:JUDITH
Other - Middle Name:SUSAN
Other - Last Name:MODZELEWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2040 BROOKSTONE CT
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-2040
Mailing Address - Country:US
Mailing Address - Phone:678-662-7258
Mailing Address - Fax:
Practice Address - Street 1:2040 BROOKSTONE CT
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-2040
Practice Address - Country:US
Practice Address - Phone:678-662-7258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0033191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA920828531AMedicaid
GA80BBFVJMedicare UPIN
GA920828531AMedicaid