Provider Demographics
NPI:1568785947
Name:JOHN, KIRK (EDD)
Entity Type:Individual
Prefix:MR
First Name:KIRK
Middle Name:
Last Name:JOHN
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 S PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-4236
Mailing Address - Country:US
Mailing Address - Phone:724-430-0555
Mailing Address - Fax:724-430-0966
Practice Address - Street 1:99 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-4236
Practice Address - Country:US
Practice Address - Phone:724-430-0555
Practice Address - Fax:724-430-0966
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS003300L103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017125050001Medicaid