Healthcare Provider Details

I. General information

NPI: 1083559272
Provider Name (Legal Business Name): CARL JUSTICE CLINTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 MAIN ST APT 303
BRATTLEBORO VT
05301-3034
US

IV. Provider business mailing address

34 DEERWOOD DR
SHERIDAN AR
72150-9626
US

V. Phone/Fax

Practice location:
  • Phone: 870-883-1194
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number101.0139620
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: