Provider Demographics
NPI:1366869844
Name:CHEN, JUSTIN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:CHEN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6106 TENNESSEE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5940
Mailing Address - Country:US
Mailing Address - Phone:610-772-3898
Mailing Address - Fax:
Practice Address - Street 1:6106 TENNESSEE AVE
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5940
Practice Address - Country:US
Practice Address - Phone:610-772-3898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4748103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical