Healthcare Provider Details

I. General information

NPI: 1972204964
Provider Name (Legal Business Name): JUSTIN OLMSTEAD MSMFT, LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 E BASELINE RD STE 109
GILBERT AZ
85234-2739
US

IV. Provider business mailing address

1734 E SILVER CREEK RD
GILBERT AZ
85296-2041
US

V. Phone/Fax

Practice location:
  • Phone: 480-341-1885
  • Fax: 602-753-9527
Mailing address:
  • Phone: 480-341-1885
  • Fax: 602-753-9527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC-21099
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: