Mark O Justic, MA LP

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

LP0329 Issued in MN

Practice address

11010 Prairie Lakes Dr
Suite 350
Eden Prairie, MN 55344-3884

Phone

(952) 746-2522

Fax

(952) 746-0887

NPI assigned

Sep 16, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Arts

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1158364800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1394582400000",
    "number": "1982700902",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1900 SILVER LAKE RD NW",
            "address_2": "110",
            "city": "NEW BRIGHTON",
            "state": "MN",
            "postal_code": "551121786",
            "telephone_number": "651-379-1718",
            "fax_number": "651-379-1738"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11010 PRAIRIE LAKES DR",
            "address_2": "SUITE 350",
            "city": "EDEN PRAIRIE",
            "state": "MN",
            "postal_code": "553443884",
            "telephone_number": "952-746-2522",
            "fax_number": "952-746-0887"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JUSTIC",
        "first_name": "MARK",
        "middle_name": "O",
        "credential": "MA LP",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-09-16",
        "last_updated": "2014-03-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "MN",
            "license": "LP0329",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "818549200",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Clinical Psychologist in Eden Prairie, MN
• Providers in Eden Prairie, MN by specialty
• Clinical Psychologist in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 12, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.