Healthcare Provider Details

I. General information

NPI: 1124309018
Provider Name (Legal Business Name): MICHAEL ANTHONY CUCCIARE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 W MARKHAM ST # 783
LITTLE ROCK AR
72205-7101
US

IV. Provider business mailing address

795 WILLOW ROAD (152)
MENLO PARK CA
94025
US

V. Phone/Fax

Practice location:
  • Phone: 501-686-8000
  • Fax: 501-526-6562
Mailing address:
  • Phone: 650-493-5000
  • Fax: 650-617-2690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY24284
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number13-05AP-PL
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: