Healthcare Provider Details

I. General information

NPI: 1851842785
Provider Name (Legal Business Name): HEATHER ANN JUDD LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

684 E VINE ST STE 4A
MURRAY UT
84107-5540
US

IV. Provider business mailing address

1646 E MAPLE AVE
SALT LAKE CITY UT
84106-3320
US

V. Phone/Fax

Practice location:
  • Phone: 801-440-9833
  • Fax:
Mailing address:
  • Phone: 801-440-9833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8600111-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: