Basic Information
| Provider Information | |||||||||
| NPI: | 1679132047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUDGE | ||||||||
| FirstName: | ROSEANNE | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PT, DPT, CLT, WCS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ERICKSON | ||||||||
| OtherFirstName: | ROSEANNE | ||||||||
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| OtherCredential: | PT, DPT, CLT, WCS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 517 ADVANCEMENT AVE APT 1 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277036490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207664692 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5920 SANDY FORKS RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276093814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199543492 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2019 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT018051 | OH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | P18913 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.