Provider Demographics
NPI:1972654424
Name:CISCO, JOHN GREGORY (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GREGORY
Last Name:CISCO
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 1:50 W SHORE RD
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-1520
Mailing Address - Country:US
Mailing Address - Phone:973-627-0348
Mailing Address - Fax:973-586-8686
Practice Address - Street 1:25 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2173
Practice Address - Country:US
Practice Address - Phone:973-586-3513
Practice Address - Fax:973-586-8686
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2526103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist