Provider Demographics
NPI:1003345968
Name:DERWART, JOHN THOMAS II
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:THOMAS
Last Name:DERWART
Suffix:II
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 1:11303 WILSHIRE BLVD BLDG 116
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5069
Mailing Address - Country:US
Mailing Address - Phone:310-914-4045
Mailing Address - Fax:
Practice Address - Street 1:11303 WILSHIRE BLVD BLDG 116
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5069
Practice Address - Country:US
Practice Address - Phone:310-914-4045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program