Provider Demographics
NPI:1265473409
Name:MIHALOVICH, JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:MIHALOVICH
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 1:2850 SE CALVIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5808
Mailing Address - Country:US
Mailing Address - Phone:772-335-5505
Mailing Address - Fax:
Practice Address - Street 1:614 NE JENSEN BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-4750
Practice Address - Country:US
Practice Address - Phone:772-370-9836
Practice Address - Fax:772-225-1226
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0002766103G00000X, 103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75297AMedicare ID - Type UnspecifiedPSYCHOLOGY