Provider Demographics
NPI:1639396641
Name:THEODORE, JOHN L (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:THEODORE
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 1:412 AVENUE OF THE AMERICAS
Mailing Address - Street 2:SUITE 413
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8409
Mailing Address - Country:US
Mailing Address - Phone:646-239-7774
Mailing Address - Fax:212-388-1215
Practice Address - Street 1:412 AVENUE OF THE AMERICAS
Practice Address - Street 2:SUITE 413
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8409
Practice Address - Country:US
Practice Address - Phone:646-239-7774
Practice Address - Fax:212-388-1215
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY68 017120103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02878408Medicaid
NYVN4431Medicare PIN