Provider Demographics
NPI:1861548141
Name:JUSTIN, CAROL MARIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:MARIE
Last Name:JUSTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:207 E BUFFALO ST
Mailing Address - Street 2:#300
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-5739
Mailing Address - Country:US
Mailing Address - Phone:414-545-1950
Mailing Address - Fax:414-271-9993
Practice Address - Street 1:207 E BUFFALO ST
Practice Address - Street 2:#300
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-5739
Practice Address - Country:US
Practice Address - Phone:414-545-1950
Practice Address - Fax:414-271-9993
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI875-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40965100ML31-078Medicaid