Healthcare Provider Details

I. General information

NPI: 1548805864
Provider Name (Legal Business Name): EDWARD HARRISON JUDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 DANBURY RD
NEW MILFORD CT
06776-4344
US

IV. Provider business mailing address

14 GELSTON AVE FL 1
BROOKLYN NY
11209-5213
US

V. Phone/Fax

Practice location:
  • Phone: 203-748-5689
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3827
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: