Provider Demographics
NPI:1447030523
Name:WHITSON, JUSTIN TYLER
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:TYLER
Last Name:WHITSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 EAST A STREET SUIT 201
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2252
Mailing Address - Country:US
Mailing Address - Phone:307-235-3333
Mailing Address - Fax:307-266-5155
Practice Address - Street 1:1300 E A ST STE 201
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2252
Practice Address - Country:US
Practice Address - Phone:307-235-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-2239101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health