Basic Information
| Provider Information | |||||||||
| NPI: | 1609904614 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JUSTICE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | OLEN | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7550 LUCERNE DR | ||||||||
| Address2: | SUITE 405 | ||||||||
| City: | MIDDLEBURG HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441306588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402348833 | ||||||||
| FaxNumber: | 4402343313 | ||||||||
| Practice Location | |||||||||
| Address1: | 2092 S CUSTER RD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481611831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342428711 | ||||||||
| FaxNumber: | 7342423955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 11/19/2010 | ||||||||
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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 | 6801086646 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.