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General NPI Number Information
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NPI Number | 1669439626
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Entity Type | Individual
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Provider Name | FREDRICK BRUCE PACKARD EDD
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Gender | Male
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Dates
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Enumeration Date | 04/26/2006
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Last Update Date | 04/09/2021
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Provider Practice Location Address
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Address Line | 160 W FISH LN
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City | SNOWFLAKE
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State | AZ
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Zip | 85937-5085
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Country | US
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Telephone | 928-225-9111
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Fax | 928-366-5988
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Provider Business Mailing Address
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Address Line | 160 W FISH LN
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City | SNOWFLAKE
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State | AZ
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Zip | 85937-5085
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Country | US
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Telephone | 928-225-9111
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Fax | 928-774-1148
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 3125
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License Number State | AZ
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