Provider Demographics
NPI:1730586470
Name:JUSTICE, GINA
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2080
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-2080
Mailing Address - Country:US
Mailing Address - Phone:304-236-5902
Mailing Address - Fax:
Practice Address - Street 1:184 E 2ND AVE
Practice Address - Street 2:STE 210
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3602
Practice Address - Country:US
Practice Address - Phone:304-236-5902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009442471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical