Provider Demographics
NPI:1760014823
Name:ST. JOHN, PHERON C
Entity Type:Individual
Prefix:
First Name:PHERON
Middle Name:C
Last Name:ST. JOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1259 GRANT AVE APT 7E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-1787
Mailing Address - Country:US
Mailing Address - Phone:917-520-8100
Mailing Address - Fax:
Practice Address - Street 1:1259 GRANT AVE APT 7E
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-1787
Practice Address - Country:US
Practice Address - Phone:917-520-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103718-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker