MEDICARE: PHOENIX COUNSELING SERVICES, LLC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1346096609
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX COUNSELING SERVICES, LLC

Provider Business Mailing Address
First Line	:	4831 COLUMBUS ST UNIT 61202
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23466-1217
Country	:	US
Telephone Number	:	757-797-4140
Fax Number	:	757-432-3280

Provider Business Practice Location Address
First Line	:	4831 COLUMBUS ST UNIT 61202
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23466-1217
Country	:	US
Telephone Number	:	757-797-4140
Fax Number	:	757-432-3280

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ALYSSA MEDINA
Credential	:	PHD, LPC
Telephone Number	:	757-797-4140

Provider Enumeration Date	:	04/27/2024
Last Update Date	:	04/27/2024

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