Provider Demographics
NPI:1477801108
Name:JUSTITIA HADDAD
Entity Type:Organization
Organization Name:JUSTITIA HADDAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COTA
Authorized Official - Prefix:
Authorized Official - First Name:JUSTITIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HADDAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-962-3312
Mailing Address - Street 1:4312 55TH AVE DRIVE EAST
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203
Mailing Address - Country:US
Mailing Address - Phone:941-962-3312
Mailing Address - Fax:
Practice Address - Street 1:4312 55TH AVE DRIVE EAST
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203
Practice Address - Country:US
Practice Address - Phone:941-962-3312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 10758174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty