Provider Demographics
NPI:1376132407
Name:JUSTIN, PATRICK THOMAS
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:THOMAS
Last Name:JUSTIN
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 1:6527 N LAKEWOOD AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-6532
Mailing Address - Country:US
Mailing Address - Phone:813-951-4162
Mailing Address - Fax:
Practice Address - Street 1:415 WASHINGTON ST STE 200
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-5564
Practice Address - Country:US
Practice Address - Phone:847-441-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health