Provider Demographics
NPI:1720077027
Name:SHOWALTER, JOHN M (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:SHOWALTER
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 1:1971 W 5TH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-1905
Mailing Address - Country:US
Mailing Address - Phone:614-488-6285
Mailing Address - Fax:614-488-9592
Practice Address - Street 1:1971 W 5TH AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-1905
Practice Address - Country:US
Practice Address - Phone:614-748-8628
Practice Address - Fax:614-488-9592
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH897103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0250900Medicaid
OH0250900Medicaid
OHCP05071Medicare PIN
R71511Medicare UPIN