Provider Demographics
NPI:1063978682
Name:GAY, JUSTIN M (LCSW)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:GAY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4776 EAGLERIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2189
Mailing Address - Country:US
Mailing Address - Phone:719-584-5183
Mailing Address - Fax:719-584-5496
Practice Address - Street 1:4776 EAGLERIDGE CIR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2189
Practice Address - Country:US
Practice Address - Phone:719-584-5183
Practice Address - Fax:719-584-5496
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI44011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI4401OtherLCSW LICENSURE