Provider Demographics
NPI:1295747079
Name:THVEDT, JOHN E (EDD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:THVEDT
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 N CHURCH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:PA
Mailing Address - Zip Code:17522-2080
Mailing Address - Country:US
Mailing Address - Phone:717-721-3890
Mailing Address - Fax:
Practice Address - Street 1:4715 VIEWRIDGE AVE STE 230
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1680
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS 008371L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018017590003Medicaid
PA090959MLGMedicare ID - Type Unspecified