Provider Demographics
NPI:1205075413
Name:NADEMIN, MAHSAW ELICIA (PHD)
Entity type:Individual
Prefix:DR
First Name:MAHSAW
Middle Name:ELICIA
Last Name:NADEMIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ELICIA
Other - Middle Name:MAHSAW
Other - Last Name:NADEMIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:3040 E CACTUS RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-7196
Mailing Address - Country:US
Mailing Address - Phone:480-221-8816
Mailing Address - Fax:602-494-3131
Practice Address - Street 1:3040 E CACTUS RD
Practice Address - Street 2:SUITE 6
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-7196
Practice Address - Country:US
Practice Address - Phone:480-221-8816
Practice Address - Fax:602-494-3131
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4018103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ406229Medicaid
AZ406229Medicaid