Healthcare Provider Details

I. General information

NPI: 1023797461
Provider Name (Legal Business Name): PHOENIX PROJECT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 04/28/2024
Certification Date: 04/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N DIXIE HWY
CAVE CITY KY
42127-9517
US

IV. Provider business mailing address

735 LEVI BEAMS RD
MAGNOLIA KY
42757-7909
US

V. Phone/Fax

Practice location:
  • Phone: 606-341-0834
  • Fax:
Mailing address:
  • Phone: 270-218-3968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: BEN STEVENS
Title or Position: OWNER
Credential: LPCC
Phone: 270-218-3968