Healthcare Provider Details

I. General information

NPI: 1447985957
Provider Name (Legal Business Name): JUSTIN EARLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2022
Last Update Date: 07/19/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

457 GRISWOLD RD
ELYRIA OH
44035-2304
US

IV. Provider business mailing address

11608 W RIDGE RD
ELYRIA OH
44035-7458
US

V. Phone/Fax

Practice location:
  • Phone: 440-406-8006
  • Fax:
Mailing address:
  • Phone: 216-798-7103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.176275
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: