Healthcare Provider Details

I. General information

NPI: 1477518249
Provider Name (Legal Business Name): EDWARD J CUMELLA PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E APACHE ST
WICKENBURG AZ
85390-2442
US

IV. Provider business mailing address

51826 N MOCKINGBIRD TRL
WICKENBURG AZ
85390-1586
US

V. Phone/Fax

Practice location:
  • Phone: 928-684-4572
  • Fax: 928-684-4594
Mailing address:
  • Phone: 480-688-0708
  • Fax: 928-684-4594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1859
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: