Provider Demographics
NPI:1144370016
Name:DENINNO, JOHN A (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:DENINNO
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 1:7500 212TH ST SW
Mailing Address - Street 2:STE 105A
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7614
Mailing Address - Country:US
Mailing Address - Phone:206-363-4205
Mailing Address - Fax:
Practice Address - Street 1:7500 212TH ST SW
Practice Address - Street 2:STE 105A
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7614
Practice Address - Country:US
Practice Address - Phone:206-363-4205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2016-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00000524103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7096407Medicaid
WA7096407Medicaid