Healthcare Provider Details

I. General information

NPI: 1407711740
Provider Name (Legal Business Name): NICOLE AMATO MA, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NIKKI AMATO MA, LAC

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 N SUMMIT AVE
PRESCOTT AZ
86301-2712
US

IV. Provider business mailing address

148 N SUMMIT AVE
PRESCOTT AZ
86301-2712
US

V. Phone/Fax

Practice location:
  • Phone: 928-308-8645
  • Fax:
Mailing address:
  • Phone: 928-308-8645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC-23880
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: