Provider Demographics
NPI:1073224762
Name:SMITH, JUSTIN (PRSS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 MACCORKLE AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177-2074
Mailing Address - Country:US
Mailing Address - Phone:304-766-0060
Mailing Address - Fax:
Practice Address - Street 1:2333 MACCORKLE AVE STE 201
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-2074
Practice Address - Country:US
Practice Address - Phone:304-766-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22-9158175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist