Healthcare Provider Details

I. General information

NPI: 1265512750
Provider Name (Legal Business Name): NATIVIDAD CANO AGS, LISAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 N DOUGLAS AVE
DOUGLAS AZ
85607-1019
US

IV. Provider business mailing address

489 N ARROYO BLVD
NOGALES AZ
85621-2644
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-1286
  • Fax: 520-805-1221
Mailing address:
  • Phone: 520-287-4713
  • Fax: 520-287-9794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC 1128
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: