Provider Demographics
NPI:1508302670
Name:BAUER, JUSTIN LEE (LCSW)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LEE
Last Name:BAUER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 SERVIDEA DR
Mailing Address - Street 2:
Mailing Address - City:RIDGWAY
Mailing Address - State:PA
Mailing Address - Zip Code:15853-6333
Mailing Address - Country:US
Mailing Address - Phone:814-776-2145
Mailing Address - Fax:814-776-1470
Practice Address - Street 1:808 S MICHAEL ST
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:PA
Practice Address - Zip Code:15857-2132
Practice Address - Country:US
Practice Address - Phone:814-834-9722
Practice Address - Fax:814-834-9723
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW193501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical