Provider Demographics
NPI:1306028105
Name:ADDIS, JOHN WESLEY (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WESLEY
Last Name:ADDIS
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 1:23 KENNEDY STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-2005
Mailing Address - Country:US
Mailing Address - Phone:814-362-2136
Mailing Address - Fax:814-362-2468
Practice Address - Street 1:23 KENNEDY STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-2005
Practice Address - Country:US
Practice Address - Phone:814-362-2136
Practice Address - Fax:814-362-2136
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS002352L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA6803636OtherVALUE OPTIONS
PA0004277250OtherAETNA
NY000507570001OtherBCBS OF WNY
PA1415000OtherMEGALLAN
PAP009953OtherTRICARE
PA00050141001OtherHMO
PA031013OtherBCBS
NY000507570001OtherBCBS OF WNY