Healthcare Provider Details

I. General information

NPI: 1265442628
Provider Name (Legal Business Name): AMANDA CHRISTINE NELLIS PH.D., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 N 16TH ST STE 102
PHOENIX AZ
85020-5266
US

IV. Provider business mailing address

17080 W SAGUARO LN
SURPRISE AZ
85388-1398
US

V. Phone/Fax

Practice location:
  • Phone: 602-734-0213
  • Fax:
Mailing address:
  • Phone: 602-301-6670
  • Fax: 623-537-1601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-2216
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number4016
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: