Provider Demographics
NPI:1780657536
Name:JOHN, DOREEN (PHD)
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3701
Mailing Address - Country:US
Mailing Address - Phone:570-283-2040
Mailing Address - Fax:
Practice Address - Street 1:601 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-3701
Practice Address - Country:US
Practice Address - Phone:570-283-2040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005644L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist