Provider Demographics
NPI:1376534263
Name:SPRUNCK TILL, TRUDI (PHD)
Entity type:Individual
Prefix:
First Name:TRUDI
Middle Name:
Last Name:SPRUNCK TILL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N SAN FRANCISCO ST
Mailing Address - Street 2:SUITE I
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4649
Mailing Address - Country:US
Mailing Address - Phone:928-774-3873
Mailing Address - Fax:928-774-3874
Practice Address - Street 1:401 N SAN FRANCISCO ST
Practice Address - Street 2:SUITE I
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4649
Practice Address - Country:US
Practice Address - Phone:928-774-3873
Practice Address - Fax:928-774-3874
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3435103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR02399Medicare UPIN
66250Medicare ID - Type Unspecified