Provider Demographics
NPI:1922883800
Name:REAVIS, JUSTIN MARK (PLADC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MARK
Last Name:REAVIS
Suffix:
Gender:M
Credentials:PLADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N COTNER BLVD STE 119
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68505-2343
Mailing Address - Country:US
Mailing Address - Phone:402-840-8339
Mailing Address - Fax:
Practice Address - Street 1:600 N COTNER BLVD STE 119
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68505-2343
Practice Address - Country:US
Practice Address - Phone:402-261-6667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-2088101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)