Healthcare Provider Details

I. General information

NPI: 1003478256
Provider Name (Legal Business Name): PHOENIX GREENWOOD-HALLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PARKLANE BLVD # 200E
DEARBORN MI
48126-2400
US

IV. Provider business mailing address

2043 N LOVINGTON DR APT 101
TROY MI
48083-4380
US

V. Phone/Fax

Practice location:
  • Phone: 313-846-2606
  • Fax: 313-846-2657
Mailing address:
  • Phone: 989-824-1633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: