Provider Demographics
NPI:1053334623
Name:NIETERS, JOHN L (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:NIETERS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10925 ANTIOCH RD STE 103
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2119
Mailing Address - Country:US
Mailing Address - Phone:913-469-6069
Mailing Address - Fax:913-469-0604
Practice Address - Street 1:10925 ANTIOCH RD STE 103
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-2119
Practice Address - Country:US
Practice Address - Phone:013-469-6069
Practice Address - Fax:913-469-0604
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLP-377103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS495713340100Medicaid
KS495713340100Medicaid
KSR89441Medicare UPIN