Basic Information
| Provider Information | |||||||||
| NPI: | 1265414445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUSTICE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1755 OREGON PIKE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175815255 | ||||||||
| FaxNumber: | 7174815259 | ||||||||
| Practice Location | |||||||||
| Address1: | 1755 OREGON PIKE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175815255 | ||||||||
| FaxNumber: | 7174815259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 10/09/2018 | ||||||||
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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 | 103G00000X | PS007009L | PA | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103T00000X | PS007009L | PA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 509767 | 01 | PA | BLUE SHIELD | OTHER |