Provider Demographics
NPI:1760482798
Name:ZIVICH, JOHN MICHAEL (PHD HSPP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:ZIVICH
Suffix:
Gender:M
Credentials:PHD HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1518
Mailing Address - Country:US
Mailing Address - Phone:219-836-8006
Mailing Address - Fax:219-962-4042
Practice Address - Street 1:32 RIDGE RD
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1518
Practice Address - Country:US
Practice Address - Phone:219-836-8806
Practice Address - Fax:219-962-4042
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-01
Last Update Date:2010-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040099A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000203122OtherNONE
IN100218620AMedicaid
IN409180IMedicare ID - Type Unspecified