Provider Demographics
NPI:1780059584
Name:DALLACQUA, JUSTIN (JD, PSYD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:DALLACQUA
Suffix:
Gender:M
Credentials:JD, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 E UNIVERSITY DR
Mailing Address - Street 2:SUITE G
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-7961
Mailing Address - Country:US
Mailing Address - Phone:602-456-2148
Mailing Address - Fax:480-718-8619
Practice Address - Street 1:408 N KENDRICK ST
Practice Address - Street 2:SUITE 3
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1582
Practice Address - Country:US
Practice Address - Phone:602-456-2148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4681103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist