Provider Demographics
NPI:1083445639
Name:AQUILA, JUSTIN DOMINIC (LMHCA)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:DOMINIC
Last Name:AQUILA
Suffix:
Gender:M
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10102 WOODLAND PLAZA CV STE A
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1573
Mailing Address - Country:US
Mailing Address - Phone:260-440-3150
Mailing Address - Fax:
Practice Address - Street 1:10102 WOODLAND PLAZA CV STE A
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1573
Practice Address - Country:US
Practice Address - Phone:260-440-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2405825-TRNE101YM0800X
IN88002895A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health