Provider Demographics
NPI:1578873923
Name:PROSSER, JOHN B (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:PROSSER
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 1:1013 LAKECREST ST
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-3446
Mailing Address - Country:US
Mailing Address - Phone:512-782-3601
Mailing Address - Fax:
Practice Address - Street 1:1013 LAKECREST ST
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-3446
Practice Address - Country:US
Practice Address - Phone:512-782-3601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-19
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25453103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical