MEDICARE: RISING PHOENIX COMMUNITY ORGANIZATION

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1710780887
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RISING PHOENIX COMMUNITY ORGANIZATION

Provider Business Mailing Address
First Line	:	PO BOX 331
Second Line	:
City	:	GROVER BEACH
State	:	CA
Zip	:	93483-0331
Country	:	US
Telephone Number	:	805-440-6471
Fax Number	:	805-941-1026

Provider Business Practice Location Address
First Line	:	558 CAMINO MERCADO
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-1815
Country	:	US
Telephone Number	:	805-941-1025
Fax Number	:	805-941-1026

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LAUREN COOK
Credential	:	BCBA
Telephone Number	:	805-440-6471

Provider Enumeration Date	:	04/01/2025
Last Update Date	:	04/01/2025

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