=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437712312
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUDY L. GUNN LCSW, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2019
-----------------------------------------------------
Last Update Date | 04/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2003 W CYPRESS CREEK RD STE 109
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33309-1834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-219-3624
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 N POMPANO BEACH BLVD APT 511
-----------------------------------------------------
City | POMPANO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33062-5742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-219-3624
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | PATTY GEORGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 321-430-1090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------