Provider Demographics
NPI:1386197416
Name:STALLER, JUSTIN (MS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:STALLER
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 AMERICAN AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-4023
Mailing Address - Country:US
Mailing Address - Phone:610-644-6464
Mailing Address - Fax:610-981-6078
Practice Address - Street 1:680 AMERICAN AVE STE 302
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-4023
Practice Address - Country:US
Practice Address - Phone:610-644-6464
Practice Address - Fax:610-981-6078
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor