Provider Demographics
NPI:1104794981
Name:SCULLY, JUSTIN M (LPC)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:M
Last Name:SCULLY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9018 W ROLLING SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-8932
Mailing Address - Country:US
Mailing Address - Phone:630-205-2603
Mailing Address - Fax:
Practice Address - Street 1:9018 W ROLLING SPRINGS DR
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85653-8932
Practice Address - Country:US
Practice Address - Phone:630-205-2603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-24
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-17262101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health