MEDICARE: KRISTY NICOLE JUSTICE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904014104	VA
2	1041C0700X	Clinical Social Worker	C019065	NC

General Provider Information

NPI Number	:	1316678121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTY NICOLE JUSTICE LCSW

Provider Business Mailing Address
First Line	:	1121 BUTTERWOOD CIR
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28314-0642
Country	:	US
Telephone Number	:	276-701-4586
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 ROYAL ST
Second Line	:
City	:	RICHLANDS
State	:	VA
Zip	:	24641-2822
Country	:	US
Telephone Number	:	276-701-4586
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2022
Last Update Date	:	06/03/2026

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