Provider Demographics
NPI:1508917907
Name:MAULDIN, JOHN TYLER JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:TYLER
Last Name:MAULDIN
Suffix:JR
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 1:2404 REFUGE RD
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-4946
Mailing Address - Country:US
Mailing Address - Phone:706-402-3524
Mailing Address - Fax:
Practice Address - Street 1:2404 REFUGE RD
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-4946
Practice Address - Country:US
Practice Address - Phone:706-402-3524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001342103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000365274BMedicaid