Provider Demographics
NPI:1447618590
Name:BAKSH, JUSTIN KALEL (MS, LMHC, MCAP)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:KALEL
Last Name:BAKSH
Suffix:
Gender:M
Credentials:MS, LMHC, MCAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5545
Mailing Address - Country:US
Mailing Address - Phone:407-780-9110
Mailing Address - Fax:
Practice Address - Street 1:160 NW CENTRAL PARK PLZ STE 105
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1825
Practice Address - Country:US
Practice Address - Phone:772-361-6778
Practice Address - Fax:772-494-7271
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH12788101YM0800X
FLMH14572101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health