Provider Demographics
NPI:1841542057
Name:FELLERS, JUDITH GAYLE (PHD)
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:GAYLE
Last Name:FELLERS
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 1:2950 SEABROOK ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29455-6221
Mailing Address - Country:US
Mailing Address - Phone:843-364-4734
Mailing Address - Fax:
Practice Address - Street 1:215 E BAY ST
Practice Address - Street 2:SUITE 403B
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-2633
Practice Address - Country:US
Practice Address - Phone:843-822-4660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3025103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool