Provider Demographics
NPI:1760116057
Name:DUNNAVANT, JUSTINE RACHELLE
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:RACHELLE
Last Name:DUNNAVANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 WATERMARK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-7088
Mailing Address - Country:US
Mailing Address - Phone:614-438-3400
Mailing Address - Fax:
Practice Address - Street 1:4055 FABER PLACE DR STE 300
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-8524
Practice Address - Country:US
Practice Address - Phone:843-641-7915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8328101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional