Provider Demographics
NPI:1124534482
Name:JUSTICE, CYNTHIA (LISW)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 ELEVENTH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTSMOUTH
Mailing Address - State:KY
Mailing Address - Zip Code:41174-9041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67 ELEVENTH ST
Practice Address - Street 2:
Practice Address - City:SOUTH PORTSMOUTH
Practice Address - State:KY
Practice Address - Zip Code:41174-9041
Practice Address - Country:US
Practice Address - Phone:740-464-8985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-22
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1700365104100000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker