Basic Information
| Provider Information | |||||||||
| NPI: | 1124309018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUCCIARE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 795 WILLOW ROAD (152) | ||||||||
| Address2: | |||||||||
| City: | MENLO PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504935000 | ||||||||
| FaxNumber: | 6506172690 | ||||||||
| Practice Location | |||||||||
| Address1: | 4301 W MARKHAM ST # 783 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722057101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016868000 | ||||||||
| FaxNumber: | 5015266562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2011 | ||||||||
| LastUpdateDate: | 09/10/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY24284 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 13-05AP-PL | AR | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.