Basic Information
| Provider Information | |||||||||
| NPI: | 1205888393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUDFORD | ||||||||
| FirstName: | GEOFFREY | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | EDD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 ACADEMY AVENUE | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237033205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574836404 | ||||||||
| FaxNumber: | 7574830737 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237033205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574836404 | ||||||||
| FaxNumber: | 7574830737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 10/19/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0701002140 | VA | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 106H00000X | 0717000203 | VA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 005409357 | 05 | VA | MEDICAID | 214324 | 01 | VA | ANTHEM BCBS | OTHER | O81365 | 01 | VA | SENTARA/OPTIMA HEALTH INS | OTHER |