Provider Demographics
NPI:1265444178
Name:WETMORE, RALPH HIGGINS II (PHD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:HIGGINS
Last Name:WETMORE
Suffix:II
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 N TUCSON BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-3423
Mailing Address - Country:US
Mailing Address - Phone:520-881-6875
Mailing Address - Fax:520-327-2298
Practice Address - Street 1:1540 N TUCSON BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-3423
Practice Address - Country:US
Practice Address - Phone:520-881-6875
Practice Address - Fax:520-327-2298
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1022103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0133210OtherBC/BS PROVIDER NUMBER
AZ115718OtherAHCCCS
AZAZ0133210OtherBC/BS PROVIDER NUMBER