Healthcare Provider Details

I. General information

NPI: 1265634364
Provider Name (Legal Business Name): JUDY ANN HAFNER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 HOPE DR BLDG 6000
MOUNTAIN HOME AFB ID
83648-1062
US

IV. Provider business mailing address

STERLING MEDICAL ASSOCIATES ATTN CREDENTIALS 411 OAK STREET
CINCINNATI OH
45219
US

V. Phone/Fax

Practice location:
  • Phone: 208-828-7580
  • Fax: 208-828-3940
Mailing address:
  • Phone: 513-984-1800
  • Fax: 513-984-4909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY-202279
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: