Healthcare Provider Details

I. General information

NPI: 1316866973
Provider Name (Legal Business Name): JUSTIN BALES LGPC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

957 PENTWOOD RD APT I
BEL AIR MD
21014-4620
US

IV. Provider business mailing address

957 PENTWOOD RD APT I
BEL AIR MD
21014-4620
US

V. Phone/Fax

Practice location:
  • Phone: 443-695-4602
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGP18010
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: