MEDICARE: MARIETTA JUSTICE MA, LPCC

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	101YP2500X	Professional Counselor	261755	KY

General Provider Information

NPI Number	:	1225435332
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIETTA JUSTICE MA, LPCC

Provider Business Mailing Address
First Line	:	350 THOMAS MORE PKWY STE 160
Second Line	:
City	:	CRESTVIEW HILLS
State	:	KY
Zip	:	41017-5460
Country	:	US
Telephone Number	:	859-600-6990
Fax Number	:	859-927-3171

Provider Business Practice Location Address
First Line	:	350 THOMAS MORE PKWY STE 160
Second Line	:
City	:	CRESTVIEW HILLS
State	:	KY
Zip	:	41017-5460
Country	:	US
Telephone Number	:	859-600-6990
Fax Number	:	859-927-3171

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

Provider Enumeration Date	:	12/04/2014
Last Update Date	:	10/24/2024

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