Provider Demographics
NPI:1760251615
Name:CODY, JUSTIN (LCPC)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:CODY
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 S CUMMINGS LN
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-2156
Mailing Address - Country:US
Mailing Address - Phone:309-472-3713
Mailing Address - Fax:
Practice Address - Street 1:722 S CUMMINGS LN
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-2156
Practice Address - Country:US
Practice Address - Phone:309-472-3713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.015707101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional