Healthcare Provider Details

I. General information

NPI: 1487969176
Provider Name (Legal Business Name): LAKISHA JESSICA NOSOV PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2010
Last Update Date: 08/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2217 W GLENDALE AVE
PHOENIX AZ
85021-7729
US

IV. Provider business mailing address

2217 W GLENDALE AVE
PHOENIX AZ
85021-7729
US

V. Phone/Fax

Practice location:
  • Phone: 623-915-8411
  • Fax: 623-915-8437
Mailing address:
  • Phone: 623-915-8411
  • Fax: 623-915-8437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number4290054
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: