Provider Demographics
NPI:1760400774
Name:ST. JOHN, DAVID GREGORY (PHD, LP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:GREGORY
Last Name:ST. JOHN
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23231 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1361
Mailing Address - Country:US
Mailing Address - Phone:734-325-0491
Mailing Address - Fax:734-207-5326
Practice Address - Street 1:23231 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1361
Practice Address - Country:US
Practice Address - Phone:734-325-0491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012887103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM21370008Medicare ID - Type Unspecified