Provider Demographics
NPI:1508406612
Name:BAILEY, JUSTIN TYLER
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:TYLER
Last Name:BAILEY
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 1:102 HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:MULLENS
Mailing Address - State:WV
Mailing Address - Zip Code:25882-1419
Mailing Address - Country:US
Mailing Address - Phone:304-294-5353
Mailing Address - Fax:304-294-8627
Practice Address - Street 1:102 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:MULLENS
Practice Address - State:WV
Practice Address - Zip Code:25882-1419
Practice Address - Country:US
Practice Address - Phone:304-294-5353
Practice Address - Fax:304-294-8627
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005489001Medicaid