=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114739497
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTINE CHLOE ST. CYR LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2025
-----------------------------------------------------
Last Update Date | 01/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2412 61ST ST
-----------------------------------------------------
City | GALVESTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77551-1802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-740-9289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 SAN MARINO DR
-----------------------------------------------------
City | GALVESTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77550-5716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-795-9557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 87675
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------