Provider Demographics
NPI:1699400648
Name:SANDBERG, JUSTIN DEAN (BA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DEAN
Last Name:SANDBERG
Suffix:
Gender:M
Credentials:BA
Other - Prefix:MR
Other - First Name:JUSTIN
Other - Middle Name:DEAN
Other - Last Name:SANDBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA
Mailing Address - Street 1:2921 N TENAYA WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-1409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2921 N TENAYA WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-1409
Practice Address - Country:US
Practice Address - Phone:702-978-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Single Specialty