Provider Demographics
NPI:1932983004
Name:STEGALL, JUSTICE R
Entity Type:Individual
Prefix:
First Name:JUSTICE
Middle Name:R
Last Name:STEGALL
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 1:107 MCEWEN CT
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-7515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:940 SR-96 E
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088
Practice Address - Country:US
Practice Address - Phone:478-988-1222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor