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NPI Code Detail

MEDICARE: ISSAC JUSTIN CONNIE M A, LPC

MEDICARE: ISSAC JUSTIN CONNIE M A, LPC
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
1101YP2500XProfessional Counselor63446TX

General Provider Information

NPI Number : 1619100427
Entity Type Code : Individual
Provider Name (Legal Business Name) : ISSAC JUSTIN CONNIE M A, LPC
Provider Business Mailing Address
First Line : 1220 W PRESIDIO ST
Second Line :
City : FORT WORTH
State : TX
Zip : 76102-4512
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1220 W PRESIDIO ST
Second Line :
City : FORT WORTH
State : TX
Zip : 76102-4512
Country : US
Telephone Number : 817-335-6429
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/26/2009
Last Update Date : 08/26/2009

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