Provider Demographics
NPI:1265442628
Name:NELLIS, AMANDA CHRISTINE (PHD, LPC)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:CHRISTINE
Last Name:NELLIS
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17080 W SAGUARO LN
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-1398
Mailing Address - Country:US
Mailing Address - Phone:602-301-6670
Mailing Address - Fax:623-537-1601
Practice Address - Street 1:7301 N 16TH ST STE 102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-5266
Practice Address - Country:US
Practice Address - Phone:602-734-0213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4016103TC1900X
AZLPC-2216101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ579401Medicaid