Healthcare Provider Details

I. General information

NPI: 1023101763
Provider Name (Legal Business Name): PHOENIX COUNSELING SERVICES, INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 PARK PLACE CIRCLE SUITE 150
MISHAWAKA IN
46545
US

IV. Provider business mailing address

P.O. BOX 1137
SOUTH BEND IN
46624
US

V. Phone/Fax

Practice location:
  • Phone: 574-276-8143
  • Fax: 574-273-2477
Mailing address:
  • Phone: 574-276-8143
  • Fax: 574-273-2477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number34003645A
License Number StateIN

VIII. Authorized Official

Name: MS. PATRICIA A. KUBOSKE
Title or Position: PRESIDENT
Credential: L.C.S.W.
Phone: 574-276-8143