Healthcare Provider Details

I. General information

NPI: 1437148426
Provider Name (Legal Business Name): JUDITH LOUDON DERRISO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 02/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 COLISEUM DR SUITE 120
MACON GA
31217-3865
US

IV. Provider business mailing address

1835 SAVOY DR SUITE 300
ATLANTA GA
30341-1072
US

V. Phone/Fax

Practice location:
  • Phone: 478-745-6130
  • Fax: 478-745-4443
Mailing address:
  • Phone: 770-495-3396
  • Fax: 770-495-2307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number426
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: