Provider Demographics
NPI:1205876158
Name:ADDISON, JUDY (LMLP, LCP)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:ADDISON
Suffix:
Gender:F
Credentials:LMLP, LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-3602
Mailing Address - Country:US
Mailing Address - Phone:316-660-7600
Mailing Address - Fax:316-383-7925
Practice Address - Street 1:1919 N AMIDON AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-2117
Practice Address - Country:US
Practice Address - Phone:316-660-7675
Practice Address - Fax:316-832-1571
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0376103TA0700X
KS037103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS2153213OtherCIGNA
KS389892OtherBLUE CROSS BLUE SHIELD