Healthcare Provider Details

I. General information

NPI: 1487991279
Provider Name (Legal Business Name): PHOENIX COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2013
Last Update Date: 01/14/2013
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: 704-884-2060
  • Fax: 704-854-4860
Mailing address:
  • Phone: 704-884-2060
  • Fax: 704-854-4860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberP007856
License Number StateNC

VIII. Authorized Official

Name: MARY C BRANNON
Title or Position: CREDENTIALING
Credential:
Phone: 704-884-2060