Provider Demographics
NPI:1114575859
Name:VASSELL, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:VASSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 PHOENIX BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-5700
Mailing Address - Country:US
Mailing Address - Phone:678-335-9010
Mailing Address - Fax:678-229-9906
Practice Address - Street 1:1903 PHOENIX BOULEVARD
Practice Address - Street 2:SUITE 200
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349
Practice Address - Country:US
Practice Address - Phone:678-335-9010
Practice Address - Fax:678-229-9906
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN169074163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1881848174OtherPSYCHIATRY