Healthcare Provider Details

I. General information

NPI: 1174111785
Provider Name (Legal Business Name): SAMANTHA MARIE SKINNER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2021
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E THUNDERBIRD RD STE 1-3
PHOENIX AZ
85022-5306
US

IV. Provider business mailing address

3620 N 3RD ST
PHOENIX AZ
85012-2020
US

V. Phone/Fax

Practice location:
  • Phone: 602-230-7373
  • Fax: 602-218-6383
Mailing address:
  • Phone: 602-230-7373
  • Fax: 602-230-5105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number19402
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: