Provider Demographics
NPI:1336225705
Name:AUSTIN, JOHN VINCENT (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:VINCENT
Last Name:AUSTIN
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 244
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55320-0244
Mailing Address - Country:US
Mailing Address - Phone:651-276-9490
Mailing Address - Fax:320-558-4066
Practice Address - Street 1:3048 FULTON CIR
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:MN
Practice Address - Zip Code:55320-1306
Practice Address - Country:US
Practice Address - Phone:651-276-9490
Practice Address - Fax:320-558-4066
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-28
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2614103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN568847700Medicaid
MN680000137Medicare ID - Type Unspecified