MEDICARE: DR. JUDY VAN DER WENDE PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY18757	CA

General Provider Information

NPI Number	:	1508928383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUDY VAN DER WENDE PH.D.

Provider Business Mailing Address
First Line	:	3695 ALAMO ST
Second Line	:	SUITE 200
City	:	SIMI VALLEY
State	:	CA
Zip	:	93063-2188
Country	:	US
Telephone Number	:	805-407-4730
Fax Number	:	805-581-0889

Provider Business Practice Location Address
First Line	:	3695 ALAMO ST
Second Line	:	SUITE 200
City	:	SIMI VALLEY
State	:	CA
Zip	:	93063-2188
Country	:	US
Telephone Number	:	805-407-4730
Fax Number	:	805-581-0889

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	07/08/2007

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