Provider Demographics
NPI:1427168491
Name:CANZONA, JOHN NICHOLAS (PSYD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:NICHOLAS
Last Name:CANZONA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18132 S. MARTIN
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2106
Mailing Address - Country:US
Mailing Address - Phone:708-957-3662
Mailing Address - Fax:708-957-3695
Practice Address - Street 1:18132 MARTIN AVE
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2106
Practice Address - Country:US
Practice Address - Phone:708-957-3662
Practice Address - Fax:708-957-3695
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL578950Medicare ID - Type Unspecified