Provider Demographics
NPI:1669652012
Name:ZELLER, JOHN EDWARD (PSYD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:ZELLER
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 1:3920 MAIN RD
Mailing Address - Street 2:
Mailing Address - City:TIVERTON
Mailing Address - State:RI
Mailing Address - Zip Code:02878-4809
Mailing Address - Country:US
Mailing Address - Phone:401-624-1879
Mailing Address - Fax:
Practice Address - Street 1:2444 E MAIN RD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:RI
Practice Address - Zip Code:02871-4025
Practice Address - Country:US
Practice Address - Phone:401-835-5041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01047103TC0700X
MA8790103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical