Healthcare Provider Details

I. General information

NPI: 1417958448
Provider Name (Legal Business Name): LISA L JUDD MSW LISW-CP ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 PARKVIEW DR
SPARTANBURG SC
29302-4019
US

IV. Provider business mailing address

504 PARKVIEW DR
SPARTANBURG SC
29302-4019
US

V. Phone/Fax

Practice location:
  • Phone: 864-504-0708
  • Fax:
Mailing address:
  • Phone: 864-504-0708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6639
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: