Provider Demographics
NPI:1851016190
Name:FLEETWOOD, JUSTIN J (LAT)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:J
Last Name:FLEETWOOD
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:967 HARDING DR
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-3817
Mailing Address - Country:US
Mailing Address - Phone:504-650-3596
Mailing Address - Fax:
Practice Address - Street 1:967 HARDING DR
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-3817
Practice Address - Country:US
Practice Address - Phone:504-650-3596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAJ-001482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer