Basic Information
| Provider Information | |||||||||
| NPI: | 1124630918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUQUA-BLACK | ||||||||
| FirstName: | JUSTINA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458041500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192221168 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2515 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FINDLAY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458403972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194255050 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2020 | ||||||||
| LastUpdateDate: | 08/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.2004707 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.