1245243237 NPI number — JUDITH TRIGG PSY.D

Table of content: JUDITH TRIGG PSY.D (NPI 1245243237)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245243237 NPI number — JUDITH TRIGG PSY.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRIGG
Provider First Name:
JUDITH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSY.D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245243237
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6975 REDANSA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61108-1201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-398-7000
Provider Business Mailing Address Fax Number:
815-395-0671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6072 BRYNWOOD DR
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61114-5829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-398-7000
Provider Business Practice Location Address Fax Number:
815-395-0671
Provider Enumeration Date:
08/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  071004991 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10132003 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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