Healthcare Provider Details

I. General information

NPI: 1033927090
Provider Name (Legal Business Name): JUSTIN GIFFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 04/12/2025
Certification Date: 04/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 EZZARD CHARLES DR
CINCINNATI OH
45214-2525
US

IV. Provider business mailing address

4224 FORSYTHIA DR
CINCINNATI OH
45245-1608
US

V. Phone/Fax

Practice location:
  • Phone: 513-381-6672
  • Fax:
Mailing address:
  • Phone: 512-270-0591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.191221
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: