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NPI Code Detail

MEDICARE: NICOLE ROGERS LISAC

MEDICARE: NICOLE ROGERS LISAC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1171M00000XCase Manager/Care Coordinator
2101YA0400XAddiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number : 1265838890
Entity Type Code : Individual
Provider Name (Legal Business Name) : NICOLE ROGERS LISAC
Provider Business Mailing Address
First Line : 3710 W GREENWAY RD STE 104
Second Line :
City : PHOENIX
State : AZ
Zip : 85053-3729
Country : US
Telephone Number : 602-466-2036
Fax Number :
Provider Business Practice Location Address
First Line : 3222 N 37TH ST
Second Line :
City : PHOENIX
State : AZ
Zip : 85018-6304
Country : US
Telephone Number : 602-599-5554
Fax Number : 602-599-5854
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/10/2014
Last Update Date : 09/29/2021

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Directions to “ NICOLE ROGERS LISAC” Practice Location

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