Healthcare Provider Details

I. General information

NPI: 1710935515
Provider Name (Legal Business Name): PHILLIP D LETT PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4222 E CAMELBACK RD H230
PHOENIX AZ
85018-2732
US

IV. Provider business mailing address

4222 E CAMELBACK RD H230
PHOENIX AZ
85018-2745
US

V. Phone/Fax

Practice location:
  • Phone: 602-852-0911
  • Fax: 602-852-0632
Mailing address:
  • Phone: 602-852-0911
  • Fax: 602-852-0632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number1627
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number1627
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1627
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1627
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1627
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: