Healthcare Provider Details

I. General information

NPI: 1326818402
Provider Name (Legal Business Name): THOMAS ANTHONY JUDGE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 E CHESTNUT ST
CHICAGO IL
60611-2014
US

IV. Provider business mailing address

5700 N MAGNOLIA AVE APT 2F
CHICAGO IL
60660-3402
US

V. Phone/Fax

Practice location:
  • Phone: 312-787-8425
  • Fax:
Mailing address:
  • Phone: 773-470-8237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: