Healthcare Provider Details

I. General information

NPI: 1821082462
Provider Name (Legal Business Name): JUDITH A YOCIUS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JUDITH DEMIDT LCSW

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 01/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1478 KENWOOD CTR SUITE 1
MENASHA WI
54952-1161
US

IV. Provider business mailing address

1478 KENWOOD CTR SUITE 1
MENASHA WI
54952-1161
US

V. Phone/Fax

Practice location:
  • Phone: 920-886-9319
  • Fax: 920-886-9357
Mailing address:
  • Phone: 920-886-9319
  • Fax: 920-886-9357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3362-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: