MEDICARE: STEPHANIE L JUSTICE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	50889	TX
2	1041C0700X	Clinical Social Worker	C007704	NC

General Provider Information

NPI Number	:	1134496102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE L JUSTICE LCSW

Provider Business Mailing Address
First Line	:	1229 JOHN AUSTIN CT
Second Line	:
City	:	KERNERSVILLE
State	:	NC
Zip	:	27284-3764
Country	:	US
Telephone Number	:	281-619-4555
Fax Number	:

Provider Business Practice Location Address
First Line	:	1229 JOHN AUSTIN CT
Second Line	:
City	:	KERNERSVILLE
State	:	NC
Zip	:	27284-3764
Country	:	US
Telephone Number	:	281-619-4555
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2011
Last Update Date	:	01/22/2013

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