Provider Demographics
NPI:1609904614
Name:JUSTICE, CHARLES OLEN (MSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:OLEN
Last Name:JUSTICE
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7550 LUCERNE DR
Mailing Address - Street 2:SUITE 405
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-6588
Mailing Address - Country:US
Mailing Address - Phone:440-234-8833
Mailing Address - Fax:440-234-3313
Practice Address - Street 1:2092 S CUSTER RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-1831
Practice Address - Country:US
Practice Address - Phone:734-242-8711
Practice Address - Fax:734-242-3955
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010866461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical