Basic Information
| Provider Information | |||||||||
| NPI: | 1932163615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUSTIC | ||||||||
| FirstName: | MARCIA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43 | ||||||||
| Address2: | MR 10809 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554400043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122624813 | ||||||||
| FaxNumber: | 6122624194 | ||||||||
| Practice Location | |||||||||
| Address1: | 2545 CHICAGO AVE | ||||||||
| Address2: | SUITE 701 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554044522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128635327 | ||||||||
| FaxNumber: | 6128632596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 04/01/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | R072870-6 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 111219800 | 05 | MN | MEDICAID |