Healthcare Provider Details

I. General information

NPI: 1366822652
Provider Name (Legal Business Name): SAMANTHA PIEKNIK PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7330 N 16TH ST STE C-200
PHOENIX AZ
85020-5237
US

IV. Provider business mailing address

7330 N 16TH ST STE C-200
PHOENIX AZ
85020-5237
US

V. Phone/Fax

Practice location:
  • Phone: 480-269-5803
  • Fax:
Mailing address:
  • Phone: 480-269-5803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number4913
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: