Provider Demographics
NPI:1780660670
Name:HALVORSON, JOHN (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HALVORSON
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:PO BOX 62
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-0062
Mailing Address - Country:US
Mailing Address - Phone:970-244-2894
Mailing Address - Fax:970-255-1809
Practice Address - Street 1:1160 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-8275
Practice Address - Country:US
Practice Address - Phone:970-244-2800
Practice Address - Fax:970-255-6291
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO511103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07005119Medicaid
COR20102Medicare UPIN
COC322138Medicare PIN