Provider Demographics
NPI:1588324438
Name:NIDAA LLC
Entity type:Organization
Organization Name:NIDAA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NGOZIKA
Authorized Official - Middle Name:VIVIAN
Authorized Official - Last Name:AMENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-799-4806
Mailing Address - Street 1:15850 N 35TH AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-3885
Mailing Address - Country:US
Mailing Address - Phone:480-799-4806
Mailing Address - Fax:
Practice Address - Street 1:15850 N 35TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-3885
Practice Address - Country:US
Practice Address - Phone:480-799-4806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-20
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health