Provider Demographics
NPI:1972924074
Name:BARRY, JUSTIN (PSYD, PSY)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:BARRY
Suffix:
Gender:M
Credentials:PSYD, PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 RUSKIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:875 W. MORENO AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905
Practice Address - Country:US
Practice Address - Phone:719-572-6100
Practice Address - Fax:719-447-4792
Is Sole Proprietor?:No
Enumeration Date:2013-12-17
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
COPSY.0004209103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator