Healthcare Provider Details

I. General information

NPI: 1295502748
Provider Name (Legal Business Name): JUSTUS MARQUIS AKINS SUDRC20179
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2023
Last Update Date: 01/27/2026
Certification Date: 01/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S 2ND AVE
COVINA CA
91723-3017
US

IV. Provider business mailing address

510 S 2ND AVE
COVINA CA
91723-3017
US

V. Phone/Fax

Practice location:
  • Phone: 626-974-8123
  • Fax:
Mailing address:
  • Phone: 626-974-0812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSUDRC20179
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: