Provider Demographics
NPI:1205343506
Name:LITTLEDIKE, JUSTIN DUANE (HIS)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DUANE
Last Name:LITTLEDIKE
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 N COOLEY ST
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84029-9359
Mailing Address - Country:US
Mailing Address - Phone:801-633-5196
Mailing Address - Fax:385-202-0542
Practice Address - Street 1:134 W 1180 N STE 5
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-1483
Practice Address - Country:US
Practice Address - Phone:435-248-2842
Practice Address - Fax:385-202-0542
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10297571-4602237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist