MEDICARE: TRUDI SPRUNCK TILL PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	3435	AZ

General Provider Information

NPI Number	:	1376534263
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRUDI SPRUNCK TILL PH.D.

Provider Business Mailing Address
First Line	:	401 N SAN FRANCISCO ST
Second Line	:	SUITE I
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-4649
Country	:	US
Telephone Number	:	928-774-3873
Fax Number	:	928-774-3874

Provider Business Practice Location Address
First Line	:	401 N SAN FRANCISCO ST
Second Line	:	SUITE I
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-4649
Country	:	US
Telephone Number	:	928-774-3873
Fax Number	:	928-774-3874

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	07/08/2007

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