Provider Demographics
NPI:1356518898
Name:CONKLIN, JUDITH L (CASAC)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:L
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5503 68TH ST
Mailing Address - Street 2:
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-1836
Mailing Address - Country:US
Mailing Address - Phone:718-505-1492
Mailing Address - Fax:
Practice Address - Street 1:9729 64TH RD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2240
Practice Address - Country:US
Practice Address - Phone:718-896-3400
Practice Address - Fax:718-459-5621
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4347101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244019Medicaid