Provider Demographics
NPI:1750333068
Name:PETZELT, JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:PETZELT
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 1:1830 INDEPENDENCE SQ
Mailing Address - Street 2:SUITE A
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-5150
Mailing Address - Country:US
Mailing Address - Phone:770-394-8845
Mailing Address - Fax:
Practice Address - Street 1:1830 INDEPENDENCE SQ
Practice Address - Street 2:SUITE A
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-5150
Practice Address - Country:US
Practice Address - Phone:770-394-8845
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY000433103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical