Healthcare Provider Details

I. General information

NPI: 1487996740
Provider Name (Legal Business Name): JUSTIN DEAN NUTT LSCSW, LCSW, LCSW,-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 COMMERCE WAY
CLOVIS NM
88101-4750
US

IV. Provider business mailing address

321 COMMERCE WAY
CLOVIS NM
88101-4750
US

V. Phone/Fax

Practice location:
  • Phone: 575-935-6262
  • Fax:
Mailing address:
  • Phone: 575-935-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8564
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10855
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: