Healthcare Provider Details

I. General information

NPI: 1922383009
Provider Name (Legal Business Name): JUSTIN SIMON M.A., LAPC, NCC, CP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 GWINNETT DR
LAWRENCEVILLE GA
30046-8444
US

IV. Provider business mailing address

40 BROOKLINE PKWY
COVINGTON GA
30014-4110
US

V. Phone/Fax

Practice location:
  • Phone: 770-339-2395
  • Fax: 678-990-3997
Mailing address:
  • Phone: 404-434-4130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPC003012
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: