Provider Demographics
NPI:1770747388
Name:DEDERICK, JUDITH G (PHD)
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:G
Last Name:DEDERICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1453 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-1131
Mailing Address - Country:US
Mailing Address - Phone:908-233-7139
Mailing Address - Fax:
Practice Address - Street 1:1453 E BROAD ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-1131
Practice Address - Country:US
Practice Address - Phone:908-233-7139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-13
Last Update Date:2008-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00170800103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist