Healthcare Provider Details

I. General information

NPI: 1154381671
Provider Name (Legal Business Name): CROSSROADS FAMILY COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 02/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4614 E SHEA BLVD
PHOENIX AZ
85028-3081
US

IV. Provider business mailing address

39737 N HIGH NOON WAY
ANTHEM AZ
85086-2376
US

V. Phone/Fax

Practice location:
  • Phone: 602-316-7134
  • Fax:
Mailing address:
  • Phone: 623-551-9234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-12149
License Number StateAZ

VIII. Authorized Official

Name: MR. TRAVIS EUGENE FRYE
Title or Position: OWNER AND FOUNDER
Credential: MA, LPC
Phone: 623-680-3486