Provider Demographics
NPI:1235179383
Name:STALLWORTH, JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:STALLWORTH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 SPICEWOOD SPRINGS RD
Mailing Address - Street 2:SUITE K-6
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8661
Mailing Address - Country:US
Mailing Address - Phone:512-417-0655
Mailing Address - Fax:512-345-8083
Practice Address - Street 1:4131 SPICEWOOD SPRINGS RD
Practice Address - Street 2:SUITE K-6
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8661
Practice Address - Country:US
Practice Address - Phone:512-417-0655
Practice Address - Fax:512-345-8083
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22668103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX309755Medicare PIN