Healthcare Provider Details

I. General information

NPI: 1366133092
Provider Name (Legal Business Name): JOHN CHARLES GEDDES PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHUCK GEDDES PHD

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3611 CROSSINGS DR STE A
PRESCOTT AZ
86305-7181
US

IV. Provider business mailing address

1180 DEERFIELD RD
PRESCOTT AZ
86303-5359
US

V. Phone/Fax

Practice location:
  • Phone: 604-791-0983
  • Fax:
Mailing address:
  • Phone: 604-791-0983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY-005529
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: