Healthcare Provider Details

I. General information

NPI: 1053886531
Provider Name (Legal Business Name): JUSTIN RAY ESTEP I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 AMERICAN GREETING CARD RD
CORBIN KY
40701-4811
US

IV. Provider business mailing address

20 HACKER FARM RD
MANCHESTER KY
40962-4868
US

V. Phone/Fax

Practice location:
  • Phone: 606-528-7010
  • Fax:
Mailing address:
  • Phone: 606-594-9712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: