Provider Demographics
NPI:1407928302
Name:JOHN E FORHETZ PHD
Entity Type:Organization
Organization Name:JOHN E FORHETZ PHD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:FORHETZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:618-344-7105
Mailing Address - Street 1:103B SOUTHPOINTE
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3651
Mailing Address - Country:US
Mailing Address - Phone:618-692-9640
Mailing Address - Fax:618-692-9643
Practice Address - Street 1:2B MEADOW HEIGHTS PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234
Practice Address - Country:US
Practice Address - Phone:618-344-7105
Practice Address - Fax:618-344-2516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty