Provider Demographics
NPI:1386741056
Name:JUDEM, DIANE KLEIN (LICSW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:KLEIN
Last Name:JUDEM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01701-2620
Mailing Address - Country:US
Mailing Address - Phone:508-788-3697
Mailing Address - Fax:508-788-3697
Practice Address - Street 1:12 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01701-2620
Practice Address - Country:US
Practice Address - Phone:508-788-3697
Practice Address - Fax:508-788-3697
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103668101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP01779Medicare UPIN
MAP01779Medicare ID - Type Unspecified