MEDICARE: DR. PHILLIP D LETT 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	103TR0400X	Rehabilitation Psychologist	1627	AZ
2	103TA0400X	Addiction (Substance Use Disorder) Psychologist	1627	AZ
3	103TC2200X	Clinical Child & Adolescent Psychologist	1627	AZ
4	103T00000X	Psychologist	1627	AZ
5	103G00000X	Clinical Neuropsychologist	1627	AZ

General Provider Information

NPI Number	:	1710935515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHILLIP D LETT PH.D.

Provider Business Mailing Address
First Line	:	4222 E CAMELBACK RD
Second Line	:	H230
City	:	PHOENIX
State	:	AZ
Zip	:	85018-2745
Country	:	US
Telephone Number	:	602-852-0911
Fax Number	:	602-852-0632

Provider Business Practice Location Address
First Line	:	4222 E CAMELBACK RD
Second Line	:	H230
City	:	PHOENIX
State	:	AZ
Zip	:	85018-2732
Country	:	US
Telephone Number	:	602-852-0911
Fax Number	:	602-852-0632

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

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	04/12/2013

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