Provider Demographics
NPI:1669403580
Name:CHELLSEN, JOHN A (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:CHELLSEN
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 1:2155 W MARCH LN
Mailing Address - Street 2:STE 2B
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6420
Mailing Address - Country:US
Mailing Address - Phone:209-473-4211
Mailing Address - Fax:209-473-0610
Practice Address - Street 1:2155 W MARCH LN
Practice Address - Street 2:STE 2B
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6420
Practice Address - Country:US
Practice Address - Phone:209-473-4211
Practice Address - Fax:209-473-0610
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8979103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical