Healthcare Provider Details

I. General information

NPI: 1023611621
Provider Name (Legal Business Name): PHILIP DAVID JUSTICE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 ARDISIA LN
SAINT JOHNS FL
32259-3881
US

IV. Provider business mailing address

PO BOX 748519
ATLANTA GA
30374-8519
US

V. Phone/Fax

Practice location:
  • Phone: 904-376-3800
  • Fax:
Mailing address:
  • Phone: 904-376-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT4409
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: