=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437580024
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STUCKEY PSYCHOLOGICAL SERVICES, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2013
-----------------------------------------------------
Last Update Date | 11/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10445 E MINNESOTA AVE
-----------------------------------------------------
City | SUN LAKES
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85248-8837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-243-5234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4980 S ALMA SCHOOL RD STE A2-429
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85248-5616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-243-5234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NORMAN STUCKEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-243-5234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY21628
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------