Provider Demographics
NPI:1942772322
Name:ASTACIO, JUSTINE
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:ASTACIO
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 1:907 DEAN AVE # 1
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10465-1609
Mailing Address - Country:US
Mailing Address - Phone:917-623-4157
Mailing Address - Fax:
Practice Address - Street 1:1 STONE PL
Practice Address - Street 2:
Practice Address - City:BRONXVILLE
Practice Address - State:NY
Practice Address - Zip Code:10708-3426
Practice Address - Country:US
Practice Address - Phone:917-623-4157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-22
Last Update Date:2018-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
009105101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health