Provider Demographics
NPI:1902286099
Name:HIRASAKI, JUSTIN HIROSHI
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:HIROSHI
Last Name:HIRASAKI
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 1:842 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1452
Mailing Address - Country:US
Mailing Address - Phone:808-277-8075
Mailing Address - Fax:
Practice Address - Street 1:605 11TH AVE E
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-5368
Practice Address - Country:US
Practice Address - Phone:208-934-8461
Practice Address - Fax:208-934-5437
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID10267101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)