Healthcare Provider Details

I. General information

NPI: 1851914816
Provider Name (Legal Business Name): PHOENIX COUNSELING AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2020
Last Update Date: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 35TH AVE
MOLINE IL
61265-6174
US

IV. Provider business mailing address

53 LONGVIEW DR
GENESEO IL
61254-9111
US

V. Phone/Fax

Practice location:
  • Phone: 309-363-2060
  • Fax:
Mailing address:
  • Phone: 309-363-2060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: L MICHELLE HOWLETT
Title or Position: LEAD THERAPIST/OWNER
Credential: LCPC
Phone: 309-363-2060