Provider Demographics
NPI:1053896936
Name:AUDETTE, JUDITH
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:AUDETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20358
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602-0358
Mailing Address - Country:US
Mailing Address - Phone:508-873-6548
Mailing Address - Fax:508-873-6548
Practice Address - Street 1:84 IRISH LN
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:MA
Practice Address - Zip Code:01543
Practice Address - Country:US
Practice Address - Phone:508-886-2855
Practice Address - Fax:508-886-2855
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1135691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical