Provider Demographics
NPI:1801051446
Name:JUSTICE, CHARLES MARTIN (MA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MARTIN
Last Name:JUSTICE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-757-0717
Mailing Address - Fax:859-331-2425
Practice Address - Street 1:20 W 18TH ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-3329
Practice Address - Country:US
Practice Address - Phone:859-757-0717
Practice Address - Fax:859-331-2425
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-23
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY262536101YM0800X
IN39002025A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health