Provider Demographics
NPI:1609410596
Name:KROLL, JUSTIN S
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:S
Last Name:KROLL
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 1:1902 13TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6238
Mailing Address - Country:US
Mailing Address - Phone:810-300-8536
Mailing Address - Fax:
Practice Address - Street 1:1902 13TH ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6238
Practice Address - Country:US
Practice Address - Phone:810-300-8536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1863405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1863Medicaid
0000000OtherDO NOT HAVE