MEDICARE: SAMANTHA PIEKNIK PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	4913	AZ
2	101Y00000X	Counselor

General Provider Information

NPI Number	:	1366822652
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA PIEKNIK PSY.D.

Provider Business Mailing Address
First Line	:	7330 N 16TH ST STE C-200
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85020-5237
Country	:	US
Telephone Number	:	480-269-5803
Fax Number	:

Provider Business Practice Location Address
First Line	:	7330 N 16TH ST STE C-200
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85020-5237
Country	:	US
Telephone Number	:	480-269-5803
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2015
Last Update Date	:	03/17/2018

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