Provider Demographics
NPI:1225450984
Name:SMITH, JUSTIN L (MA, LPCC)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42502-0002
Mailing Address - Country:US
Mailing Address - Phone:606-451-9379
Mailing Address - Fax:606-451-8149
Practice Address - Street 1:100 E SOMERSET CHURCH RD
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-4977
Practice Address - Country:US
Practice Address - Phone:606-451-9379
Practice Address - Fax:606-451-8149
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100370000Medicaid