Provider Demographics
NPI:1609347533
Name:FITTONNEVILLE, JUSTIN (MA, LPC, NCC)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:FITTONNEVILLE
Suffix:
Gender:M
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 W WALTON BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-4191
Mailing Address - Country:US
Mailing Address - Phone:248-461-6266
Mailing Address - Fax:
Practice Address - Street 1:4000 W WALTON BLVD STE A&B
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-4191
Practice Address - Country:US
Practice Address - Phone:248-461-6266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014329101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional