Provider Demographics
NPI:1013524719
Name:NOEL, RICHARD DAVID
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DAVID
Last Name:NOEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91493
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85752-1493
Mailing Address - Country:US
Mailing Address - Phone:520-631-3681
Mailing Address - Fax:
Practice Address - Street 1:4565 W LORD REDMAN LOOP
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-4042
Practice Address - Country:US
Practice Address - Phone:520-631-3681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-26
Last Update Date:2020-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TR0400X, 106S00000X
AZ3009524163WP0000X, 225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic TherapistGroup - Multi-Specialty
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No163WP0000XNursing Service ProvidersRegistered NursePain ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ601637737Medicaid