Healthcare Provider Details

I. General information

NPI: 1093976763
Provider Name (Legal Business Name): JUDITH GRETCHEN OGDEN LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2203 MONTEREY DR
SOUTH LAKE TAHOE CA
96150-6729
US

IV. Provider business mailing address

PO BOX 8285
SOUTH LAKE TAHOE CA
96158-1285
US

V. Phone/Fax

Practice location:
  • Phone: 530-544-8580
  • Fax:
Mailing address:
  • Phone: 530-544-8580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number33598
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0760
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: