Provider Demographics
NPI:1255368833
Name:JUDD, THEODORE LEWIS (PHD)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:LEWIS
Last Name:JUDD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12 BELLWETHER WAY
Mailing Address - Street 2:STE 223
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2914
Mailing Address - Country:US
Mailing Address - Phone:360-543-8333
Mailing Address - Fax:360-543-8332
Practice Address - Street 1:12 BELLWETHER WAY
Practice Address - Street 2:SUITE 223
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2959
Practice Address - Country:US
Practice Address - Phone:360-255-2505
Practice Address - Fax:360-255-2504
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00000736103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7115900Medicaid
WAAB11465Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
WA7115900Medicaid