Fredrick Bruce Packard, EDD
Individual provider Active NPI Psychologist · Snowflake, AZ
NPI 1669439626 · NPPES record last updated Apr 9, 2021
Key facts
- NPI
- 1669439626
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Psychologist 103T00000X
- License
- 3125 (AZ)
- Practice address
- 160 W Fish LN
Snowflake, AZ 85937-5085 - Phone
- (928) 225-9111
- Fax
- (928) 366-5988
- NPI assigned
- Apr 26, 2006
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 3125 | AZ | MD | Psychologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Krietsch & Daiss PC | Past | Accepting new patients | |
| Choices Integrative Health Care | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | 3125 | AZ | Yes |
Addresses
Primary practice location
160 W Fish LN
Snowflake, AZ 85937-5085
Mailing address
160 W Fish LN
Snowflake, AZ 85937-5085
Phone (928) 225-9111
Other practice location 1
160 W Fish Ln
Snowflake, AZ 85937-5085
Phone (928) 225-9111
Other practice location 2
160 W Fish Ln
Snowflake, AZ 85937-5085
Phone (928) 225-9111
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 3125 | Other | AZ | LICENSE NUMBER |
Other providers in Snowflake, AZ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 9, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.