Healthcare Provider Details

I. General information

NPI: 1821349408
Provider Name (Legal Business Name): JUSTIN EVERETT WASSEL LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2012
Last Update Date: 09/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 GRIEGOS RD NW
ALBUQUERQUE NM
87107-3752
US

IV. Provider business mailing address

625 FIELDSTREAM BLVD
ORLANDO FL
32825-7209
US

V. Phone/Fax

Practice location:
  • Phone: 505-345-8471
  • Fax: 505-342-5495
Mailing address:
  • Phone: 407-459-2066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0151341
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: