Healthcare Provider Details

I. General information

NPI: 1023144003
Provider Name (Legal Business Name): JUDSON H. PHELPS LADC 1
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 TER HEUN DR
FALMOUTH MA
02540-2525
US

IV. Provider business mailing address

53 GINGERBREAD LN
YARMOUTH PORT MA
02675-1110
US

V. Phone/Fax

Practice location:
  • Phone: 508-540-6550
  • Fax: 508-540-7480
Mailing address:
  • Phone: 508-362-5921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number523
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: