Healthcare Provider Details

I. General information

NPI: 1093370793
Provider Name (Legal Business Name): JUSTIN W HETTINGER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4653 E MAIN ST
WHITEHALL OH
43213-3298
US

IV. Provider business mailing address

4653 E MAIN ST
WHITEHALL OH
43213-3298
US

V. Phone/Fax

Practice location:
  • Phone: 614-384-7798
  • Fax:
Mailing address:
  • Phone: 614-384-7798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2002750
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: