Provider Demographics
NPI:1184373474
Name:ROBERTS, JUSTIN SCOTT (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:SCOTT
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12301 WILSHIRE BLVD STE 512
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1053
Mailing Address - Country:US
Mailing Address - Phone:888-684-2779
Mailing Address - Fax:
Practice Address - Street 1:12301 WILSHIRE BLVD STE 512
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1053
Practice Address - Country:US
Practice Address - Phone:888-684-2779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020363363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health