Healthcare Provider Details

I. General information

NPI: 1972924074
Provider Name (Legal Business Name): JUSTIN BARRY PSYD, PSY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2013
Last Update Date: 04/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 W. MORENO AVE
COLORADO SPRINGS CO
80905
US

IV. Provider business mailing address

220 RUSKIN DRIVE
COLORADO SPRINGS CO
80910
US

V. Phone/Fax

Practice location:
  • Phone: 719-572-6100
  • Fax: 719-447-4792
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY.0004209
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: