Basic Information
| Provider Information | |||||||||
| NPI: | 1699024745 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERSOON | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1686 N LAKESHORE DR | ||||||||
| Address2: | |||||||||
| City: | LUDINGTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494319403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2312336576 | ||||||||
| FaxNumber: | 2318457095 | ||||||||
| Practice Location | |||||||||
| Address1: | 1686 N LAKESHORE DR | ||||||||
| Address2: | |||||||||
| City: | LUDINGTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494319403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2312336576 | ||||||||
| FaxNumber: | 2318457095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2012 | ||||||||
| LastUpdateDate: | 01/09/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-16-22081 | MI | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 101YP2500X | 6401013191 | MI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 103T00000X | 6301015191 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.