Provider Demographics
NPI:1871599134
Name:IRVIN, JUDY A (LCSW)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:A
Last Name:IRVIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 COMMERCIAL ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5203
Mailing Address - Country:US
Mailing Address - Phone:503-315-2041
Mailing Address - Fax:
Practice Address - Street 1:1845 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5203
Practice Address - Country:US
Practice Address - Phone:503-315-2041
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL31591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
114589Medicare ID - Type Unspecified