Basic Information
| Provider Information | |||||||||
| NPI: | 1710187760 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COTTON | ||||||||
| FirstName: | JUDA | ||||||||
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| Credential: | LPCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4473 PEA RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | WADDY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400766151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028290059 | ||||||||
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| Practice Location | |||||||||
| Address1: | 250 ALPINE DR | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400658880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025891100 | ||||||||
| FaxNumber: | 5025898771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2007 | ||||||||
| LastUpdateDate: | 06/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1790731081 | 05 | KY | MEDICAID |