Provider Demographics
NPI:1396961066
Name:HARTKE, JOHN M (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:HARTKE
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 1:100 CHETWYND DR
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-1453
Mailing Address - Country:US
Mailing Address - Phone:610-526-9110
Mailing Address - Fax:
Practice Address - Street 1:100 CHETWYND DR
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-1453
Practice Address - Country:US
Practice Address - Phone:610-526-9110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS002473L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAHA338174OtherPSYCHOLOGIST
PA027145Medicare ID - Type UnspecifiedPSYCHOLOGIST