Healthcare Provider Details

I. General information

NPI: 1821113895
Provider Name (Legal Business Name): BRETT M. JUDD LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 E LANDER #201
POCATELLO ID
83201-6319
US

IV. Provider business mailing address

15149 W LACEY
POCATELLO ID
83202-5044
US

V. Phone/Fax

Practice location:
  • Phone: 208-904-3225
  • Fax: 208-904-3227
Mailing address:
  • Phone: 208-904-3225
  • Fax: 208-904-3227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZE0500X
TaxonomyEEG Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-38601
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: