Provider Demographics
NPI:1174715577
Name:SINA, JUDY JAIJAETAWAKWE (PHD)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:JAIJAETAWAKWE
Last Name:SINA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:TAWA
Other - Middle Name:
Other - Last Name:SINA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5786 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-8436
Mailing Address - Country:US
Mailing Address - Phone:517-862-1267
Mailing Address - Fax:
Practice Address - Street 1:5786 LAKE DR
Practice Address - Street 2:
Practice Address - City:HASLETT
Practice Address - State:MI
Practice Address - Zip Code:48840-8436
Practice Address - Country:US
Practice Address - Phone:517-862-1267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011292103TC1900X, 103TH0004X, 103TP2701X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation