Basic Information
| Provider Information | |||||||||
| NPI: | 1720456635 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LITTLE | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | GERALD BIXBY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 605 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986660605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606951325 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 309 W 12TH ST | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606951325 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2015 | ||||||||
| LastUpdateDate: | 05/30/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 78208 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | LF60817829 | WA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.