Provider Demographics
NPI:1083483382
Name:MILLARD, JUSTIN CAREY (MS, LAC)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:CAREY
Last Name:MILLARD
Suffix:
Gender:M
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 E OSBORN RD UNIT 203
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-5249
Mailing Address - Country:US
Mailing Address - Phone:480-307-0627
Mailing Address - Fax:
Practice Address - Street 1:655 W GURLEY ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-3619
Practice Address - Country:US
Practice Address - Phone:877-305-2637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-20226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health