Provider Demographics
NPI:1629299367
Name:NOCKLEBY, DONALD M (PHD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:M
Last Name:NOCKLEBY
Suffix:
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 1:3625 N 16TH ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-6443
Mailing Address - Country:US
Mailing Address - Phone:602-271-6165
Mailing Address - Fax:
Practice Address - Street 1:3625 N 16TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-6443
Practice Address - Country:US
Practice Address - Phone:602-271-6165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1583103G00000X, 103TA0700X
TX33310103G00000X, 103TA0700X
MT178103G00000X, 103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1629299367Medicare UPIN
AZ1629299367Medicare UPIN