Provider Demographics
NPI:1942956503
Name:BINGHAM, JUSTIN (ASW)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:BINGHAM
Suffix:
Gender:M
Credentials:ASW
Other - Prefix:
Other - First Name:JUSTINE
Other - Middle Name:
Other - Last Name:BINGHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ASW
Mailing Address - Street 1:1620 SANTA CLARA DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3559
Mailing Address - Country:US
Mailing Address - Phone:916-786-3750
Mailing Address - Fax:
Practice Address - Street 1:1620 SANTA CLARA DR STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3559
Practice Address - Country:US
Practice Address - Phone:916-786-3750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW122515104100000X
175T00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No175T00000XOther Service ProvidersPeer Specialist