Provider Demographics
NPI:1346068624
Name:CIASULLO, JUSTIN WYATT
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:WYATT
Last Name:CIASULLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28561 KALMIA AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-6521
Mailing Address - Country:US
Mailing Address - Phone:951-743-6921
Mailing Address - Fax:
Practice Address - Street 1:239 W 9TH ST
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5979
Practice Address - Country:US
Practice Address - Phone:909-981-6121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-26
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19137101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)