Provider Demographics
NPI:1487011284
Name:WIXSON, JUSTIN (LCAT)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:WIXSON
Suffix:
Gender:M
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 VIOLET PL
Mailing Address - Street 2:
Mailing Address - City:RHINEBECK
Mailing Address - State:NY
Mailing Address - Zip Code:12572-1621
Mailing Address - Country:US
Mailing Address - Phone:315-380-3211
Mailing Address - Fax:
Practice Address - Street 1:23 E MARKET ST
Practice Address - Street 2:SUITE H
Practice Address - City:RHINEBECK
Practice Address - State:NY
Practice Address - Zip Code:12572-1639
Practice Address - Country:US
Practice Address - Phone:315-380-3211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001790101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor