Provider Demographics
NPI:1891117677
Name:MINK, JUSTIN (LPC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:MINK
Suffix:
Gender:M
Credentials:LPC
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 1085
Mailing Address - Street 2:
Mailing Address - City:PAWCATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06379-0085
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43 BROAD ST
Practice Address - Street 2:3RD FLOOR, SUITE D, UNIT 2
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-1977
Practice Address - Country:US
Practice Address - Phone:401-226-7407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002446101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional