Provider Demographics
NPI:1669439626
Name:PACKARD, FREDRICK BRUCE (EDD)
Entity Type:Individual
Prefix:DR
First Name:FREDRICK
Middle Name:BRUCE
Last Name:PACKARD
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 W FISH LN
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-5085
Mailing Address - Country:US
Mailing Address - Phone:928-225-9111
Mailing Address - Fax:928-774-1148
Practice Address - Street 1:160 W FISH LN
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-5085
Practice Address - Country:US
Practice Address - Phone:928-225-9111
Practice Address - Fax:928-366-5988
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3125103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3125OtherLICENSE NUMBER