Provider Demographics
NPI:1518574961
Name:PARKER, JUSTIN (LCAS-A, LCMHC-A)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:PARKER
Suffix:
Gender:M
Credentials:LCAS-A, LCMHC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 VIRGINIA DARE TRL N
Mailing Address - Street 2:
Mailing Address - City:KITTY HAWK
Mailing Address - State:NC
Mailing Address - Zip Code:27949-4079
Mailing Address - Country:US
Mailing Address - Phone:252-242-3900
Mailing Address - Fax:
Practice Address - Street 1:3512 VIRGINIA DARE TRL N
Practice Address - Street 2:
Practice Address - City:KITTY HAWK
Practice Address - State:NC
Practice Address - Zip Code:27949-4079
Practice Address - Country:US
Practice Address - Phone:252-242-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15964101YM0800X
NCLCAS-26586101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health