Healthcare Provider Details

I. General information

NPI: 1760482798
Provider Name (Legal Business Name): JOHN MICHAEL ZIVICH PHD HSPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 03/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 RIDGE RD
MUNSTER IN
46321-1518
US

IV. Provider business mailing address

32 RIDGE RD
MUNSTER IN
46321-1518
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-8806
  • Fax: 219-962-4042
Mailing address:
  • Phone: 219-836-8006
  • Fax: 219-962-4042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20040099A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: