Provider Demographics
NPI:1316940182
Name:TUDIVER, JUDITH G (PHD)
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:G
Last Name:TUDIVER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3337 BONDWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-8904
Mailing Address - Country:US
Mailing Address - Phone:423-341-4752
Mailing Address - Fax:423-283-0931
Practice Address - Street 1:415 E UNAKA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4030
Practice Address - Country:US
Practice Address - Phone:423-341-4752
Practice Address - Fax:423-283-0931
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000002479103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN540270000OtherMAGELLAN MIS
TN229346OtherCOMPSYCH
TN4065358OtherBS PIN-UNAKA ADDRESS
TN3982954Medicaid
TN4065358OtherBC BS TN PIN
TN7270161OtherAETNA PIN
VA010300860Medicaid
TN4065358OtherBC BS TN PIN