Provider Demographics
NPI:1306389986
Name:SALLS, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SALLS
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 1:254 PLAINFIELD RD UNIT 1
Mailing Address - Street 2:
Mailing Address - City:WEST LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03784-2001
Mailing Address - Country:US
Mailing Address - Phone:603-298-2146
Mailing Address - Fax:603-298-2149
Practice Address - Street 1:254 PLAINFIELD RD UNIT 1
Practice Address - Street 2:
Practice Address - City:WEST LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03784-2001
Practice Address - Country:US
Practice Address - Phone:603-298-2146
Practice Address - Fax:603-298-2149
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1023175072Medicaid