Healthcare Provider Details

I. General information

NPI: 1629299367
Provider Name (Legal Business Name): DONALD M NOCKLEBY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 04/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 N 16TH ST SUITE 104
PHOENIX AZ
85016-6443
US

IV. Provider business mailing address

3625 N 16TH ST SUITE 104
PHOENIX AZ
85016-6443
US

V. Phone/Fax

Practice location:
  • Phone: 602-271-6165
  • Fax:
Mailing address:
  • Phone: 602-271-6165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1583
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number33310
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number178
License Number StateMT
# 4
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number1583
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number33310
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number178
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: