Provider Demographics
NPI:1346052362
Name:MICKENBERG, JUDITH H (LICSW)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:H
Last Name:MICKENBERG
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:HOPE
Other - Last Name:ENGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSW, MSW
Mailing Address - Street 1:45 FOREST HILL DR
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:MA
Mailing Address - Zip Code:01235-3503
Mailing Address - Country:US
Mailing Address - Phone:508-250-5754
Mailing Address - Fax:
Practice Address - Street 1:45 FOREST HILL DR
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:MA
Practice Address - Zip Code:01235-3503
Practice Address - Country:US
Practice Address - Phone:508-250-5754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-25
Last Update Date:2025-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA111876101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health