Healthcare Provider Details

I. General information

NPI: 1598074841
Provider Name (Legal Business Name): PHOENIX COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2010
Last Update Date: 04/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 COURT DR
GASTONIA NC
28054-2140
US

IV. Provider business mailing address

2505 COURT DR
GASTONIA NC
28054-2140
US

V. Phone/Fax

Practice location:
  • Phone: 704-842-6333
  • Fax: 704-854-4860
Mailing address:
  • Phone: 704-842-6333
  • Fax: 704-854-4860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP004885
License Number StateNC

VIII. Authorized Official

Name: MRS. JESSIE HOLBROOK GREEN
Title or Position: CLINICIAN
Credential: MSW, LCSW
Phone: 704-842-6333