Provider Demographics
NPI:1407639446
Name:SPANN, JUSTIN SLADE (CAC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:SLADE
Last Name:SPANN
Suffix:
Gender:M
Credentials:CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6564 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-2701
Mailing Address - Country:US
Mailing Address - Phone:318-435-7558
Mailing Address - Fax:318-435-0480
Practice Address - Street 1:6564 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-2701
Practice Address - Country:US
Practice Address - Phone:318-435-7558
Practice Address - Fax:318-435-0480
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5056101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)