Provider Demographics
NPI:1487680641
Name:PEHLE, JOHN WILLIAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:PEHLE
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 1:1024 J ST STE 412
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0844
Mailing Address - Country:US
Mailing Address - Phone:209-577-1159
Mailing Address - Fax:209-823-8189
Practice Address - Street 1:1024 J ST STE 412
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0844
Practice Address - Country:US
Practice Address - Phone:209-577-1159
Practice Address - Fax:209-823-8189
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5304103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY053040Medicaid
CAR26209Medicare ID - Type UnspecifiedPSYCHOLOGIST
CAOOPL53041Medicare UPIN