Provider Demographics
NPI:1992897227
Name:THORNDIKE, JUDETH L (LISAC, BSBA)
Entity type:Individual
Prefix:
First Name:JUDETH
Middle Name:L
Last Name:THORNDIKE
Suffix:
Gender:F
Credentials:LISAC, BSBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 CALLE PORTAL
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2900
Mailing Address - Country:US
Mailing Address - Phone:520-459-3012
Mailing Address - Fax:520-515-8663
Practice Address - Street 1:335 S OCOTILLO AVE
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:AZ
Practice Address - Zip Code:85602
Practice Address - Country:US
Practice Address - Phone:520-586-4040
Practice Address - Fax:520-586-4423
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC1602101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ917510OtherAHCCCS