1083155667 NPI number — PHOENIX RISING COUNSELING SERVICES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083155667 NPI number — PHOENIX RISING COUNSELING SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX RISING COUNSELING SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083155667
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
863 FLAT SHOALS RD SE
Provider Second Line Business Mailing Address:
SUITE C #149
Provider Business Mailing Address City Name:
CONYERS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30094-6633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-824-2010
Provider Business Mailing Address Fax Number:
888-705-0482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 COLSER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30016-0991
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-824-2010
Provider Business Practice Location Address Fax Number:
888-705-0482
Provider Enumeration Date:
03/15/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WOOD
Authorized Official First Name:
AUNDRETTA
Authorized Official Middle Name:
MYKEL
Authorized Official Title or Position:
OWNER/THERAPIST
Authorized Official Telephone Number:
678-824-2010

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  CSW005912 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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