Provider Demographics
NPI:1760244313
Name:NIXON, SAMANTHA (LISAC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:NIXON
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 E OSBORN RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7236
Mailing Address - Country:US
Mailing Address - Phone:602-263-5242
Mailing Address - Fax:602-595-4434
Practice Address - Street 1:14240 N 43RD AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4511
Practice Address - Country:US
Practice Address - Phone:602-263-5242
Practice Address - Fax:602-595-4434
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15403101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)