Provider Demographics
NPI:1982776324
Name:DETTWYLER, JOHN WILLIAM (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:DETTWYLER
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 1:5301 LIMESTONE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-1250
Mailing Address - Country:US
Mailing Address - Phone:302-234-8982
Mailing Address - Fax:302-234-8984
Practice Address - Street 1:5301 LIMESTONE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-1250
Practice Address - Country:US
Practice Address - Phone:302-234-8982
Practice Address - Fax:302-234-8984
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB10000210103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000025979Medicaid
DE0000621543Medicaid
DE621543Medicare ID - Type Unspecified