Provider Demographics
NPI:1275189177
Name:GOUBEAUX, JUSTIN (CDCA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:GOUBEAUX
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45426-2909
Mailing Address - Country:US
Mailing Address - Phone:937-270-3329
Mailing Address - Fax:
Practice Address - Street 1:714 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TROTWOOD
Practice Address - State:OH
Practice Address - Zip Code:45426-2909
Practice Address - Country:US
Practice Address - Phone:937-270-3329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.171147101YM0800X, 101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator