Provider Demographics
NPI:1972153682
Name:MCCOY, JUSTIN BENJAMIN (LLPC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:BENJAMIN
Last Name:MCCOY
Suffix:
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3351 CLAYSTONE ST SE STE G32
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5794
Mailing Address - Country:US
Mailing Address - Phone:616-219-0499
Mailing Address - Fax:
Practice Address - Street 1:3351 CLAYSTONE ST SE STE G32
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5794
Practice Address - Country:US
Practice Address - Phone:616-219-0499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-14
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017700101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health