Provider Demographics
NPI:1699794644
Name:HEROLDT, JOHN THOMAS (EDD, HSPP)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:HEROLDT
Suffix:
Gender:M
Credentials:EDD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1652 TIPPECANOE CT
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-6142
Mailing Address - Country:US
Mailing Address - Phone:219-874-2518
Mailing Address - Fax:
Practice Address - Street 1:717 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3371
Practice Address - Country:US
Practice Address - Phone:219-874-2518
Practice Address - Fax:219-756-8945
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040372A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1699794644Medicare PIN
IN229740Medicare ID - Type Unspecified
INP00226515Medicare ID - Type UnspecifiedRAILROAD MEDICARE