Healthcare Provider Details

I. General information

NPI: 1215070065
Provider Name (Legal Business Name): JUSTIN M DOUB LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E CHESTNUT ST UNIT 610
LOUISVILLE KY
40202-5711
US

IV. Provider business mailing address

401 E CHESTNUT ST UNIT 600
LOUISVILLE KY
40202-5705
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-4450
  • Fax: 502-588-9539
Mailing address:
  • Phone: 502-588-4425
  • Fax: 502-588-4427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5061
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: