Healthcare Provider Details

I. General information

NPI: 1336351261
Provider Name (Legal Business Name): JUDITH SUSAN ASHWORTH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JUDITH SUSAN MODZELEWSKI LCSW

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 BROOKSTONE CT
LITHIA SPRINGS GA
30122-2040
US

IV. Provider business mailing address

2040 BROOKSTONE CT
LITHIA SPRINGS GA
30122-2040
US

V. Phone/Fax

Practice location:
  • Phone: 678-662-7258
  • Fax:
Mailing address:
  • Phone: 678-662-7258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number003319
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier920828531A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: