Provider Demographics
NPI:1366555146
Name:SMITH, JUDY L (PHD)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:L
Last Name:SMITH
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 1:641 OAKLEAF OFFICE LN
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-4819
Mailing Address - Country:US
Mailing Address - Phone:901-680-0080
Mailing Address - Fax:901-383-1507
Practice Address - Street 1:641 OAKLEAF OFFICE LN
Practice Address - Street 2:SUITE 3
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4819
Practice Address - Country:US
Practice Address - Phone:901-680-0080
Practice Address - Fax:901-383-1507
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP1046103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0127281OtherBCBS ID NUMBER
3689556Medicare ID - Type Unspecified