Provider Demographics
NPI:1437927753
Name:WARD, JUSTIN D
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:D
Last Name:WARD
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 1:2903 CANTERBURY BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-3205
Mailing Address - Country:US
Mailing Address - Phone:336-580-4582
Mailing Address - Fax:
Practice Address - Street 1:1400 AIRPORT NORTH OFFICE PARK STE D
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-6723
Practice Address - Country:US
Practice Address - Phone:133-658-0458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist