Basic Information
| Provider Information | |||||||||
| NPI: | 1215070065 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUB | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 E CHESTNUT ST UNIT 600 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402025705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025884425 | ||||||||
| FaxNumber: | 5025884427 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 E CHESTNUT ST UNIT 610 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402025711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025884450 | ||||||||
| FaxNumber: | 5025889539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 5061 | KY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 30605018 | 05 | KY | MEDICAID |