Healthcare Provider Details

I. General information

NPI: 1730594631
Provider Name (Legal Business Name): JUSTIN MCDANIEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 W PROFESSIONAL PARK CT STE 1
BOWLING GREEN KY
42104-3250
US

IV. Provider business mailing address

PO BOX 51322
BOWLING GREEN KY
42102-5622
US

V. Phone/Fax

Practice location:
  • Phone: 270-843-5300
  • Fax: 270-843-5383
Mailing address:
  • Phone: 270-777-9283
  • Fax: 270-777-9283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberABALBA00218345
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: