Provider Demographics
NPI:1366564635
Name:GERVAIS, JUDY NAOMI (LMT, AAS)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:NAOMI
Last Name:GERVAIS
Suffix:
Gender:F
Credentials:LMT, AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356 SW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-2201
Mailing Address - Country:US
Mailing Address - Phone:541-420-0072
Mailing Address - Fax:
Practice Address - Street 1:356 SW 6TH ST
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2201
Practice Address - Country:US
Practice Address - Phone:541-420-0072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10788174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist