Healthcare Provider Details

I. General information

NPI: 1265838890
Provider Name (Legal Business Name): NICOLE ROGERS LISAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3222 N 37TH ST
PHOENIX AZ
85018-6304
US

IV. Provider business mailing address

3710 W GREENWAY RD STE 104
PHOENIX AZ
85053-3729
US

V. Phone/Fax

Practice location:
  • Phone: 602-599-5554
  • Fax: 602-599-5854
Mailing address:
  • Phone: 602-466-2036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: