Provider Demographics
NPI:1417660663
Name:DEITRICK, JUSTIN (LGPC)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:DEITRICK
Suffix:
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 CHAMPIONSHIP DR
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21738-9311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3700 CHAMPIONSHIP DR
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MD
Practice Address - Zip Code:21738-9311
Practice Address - Country:US
Practice Address - Phone:443-472-1349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YS0200X
MDLGP1399101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool