Provider Demographics
NPI:1659604791
Name:HART, JOHN K
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:K
Last Name:HART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 ASHLEY BROOK SQ
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3111
Mailing Address - Country:US
Mailing Address - Phone:336-765-6577
Mailing Address - Fax:
Practice Address - Street 1:125 ASHLEY BROOK SQ
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3111
Practice Address - Country:US
Practice Address - Phone:336-765-6577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC002857104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker