Provider Demographics
NPI:1407330368
Name:GENOVA, JUSTIN P
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:P
Last Name:GENOVA
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 1:96 IRONWEED DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1048
Mailing Address - Country:US
Mailing Address - Phone:719-320-3361
Mailing Address - Fax:
Practice Address - Street 1:2429 S PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2886
Practice Address - Country:US
Practice Address - Phone:719-564-5070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)