Healthcare Provider Details

I. General information

NPI: 1306327770
Provider Name (Legal Business Name): JOHNWICK NATHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6736 W CARSON RD
LAVEEN AZ
85339-7024
US

IV. Provider business mailing address

3950 W CHANDLER BLVD APT 3049
CHANDLER AZ
85226-2662
US

V. Phone/Fax

Practice location:
  • Phone: 860-938-6845
  • Fax:
Mailing address:
  • Phone: 860-938-6845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: