Healthcare Provider Details

I. General information

NPI: 1174694954
Provider Name (Legal Business Name): DOUG SUMMERS LISAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6376 W BELL RD
GLENDALE AZ
85308-3602
US

IV. Provider business mailing address

2017 N 7TH ST
PHOENIX AZ
85006-2102
US

V. Phone/Fax

Practice location:
  • Phone: 623-486-8202
  • Fax: 623-486-2739
Mailing address:
  • Phone: 602-452-4684
  • Fax: 602-358-0399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLISAC0102
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: