Healthcare Provider Details

I. General information

NPI: 1386108132
Provider Name (Legal Business Name): JUSTIN CRAIG TROUT LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2019
Last Update Date: 01/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 CUMBERLAND RD
CEDAR BLUFF VA
24609-1137
US

IV. Provider business mailing address

PO BOX 810
CEDAR BLUFF VA
24609-0810
US

V. Phone/Fax

Practice location:
  • Phone: 276-964-6702
  • Fax: 276-964-0292
Mailing address:
  • Phone: 276-964-6702
  • Fax: 276-964-0292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701008081
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: