Provider Demographics
NPI:1750587739
Name:BLISS, JUDSON R (LPC, LCSW)
Entity type:Individual
Prefix:DR
First Name:JUDSON
Middle Name:R
Last Name:BLISS
Suffix:
Gender:M
Credentials:LPC, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PREMIER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2943
Mailing Address - Country:US
Mailing Address - Phone:314-544-3800
Mailing Address - Fax:
Practice Address - Street 1:500 CLARK AVE
Practice Address - Street 2:ST A
Practice Address - City:UNION
Practice Address - State:MO
Practice Address - Zip Code:63084-1004
Practice Address - Country:US
Practice Address - Phone:636-583-1800
Practice Address - Fax:636-583-0836
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070195601041C0700X
MO002010101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical