Healthcare Provider Details

I. General information

NPI: 1679937932
Provider Name (Legal Business Name): PHOENIX COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 E CENTER AVE
MOORESVILLE NC
28115-2547
US

IV. Provider business mailing address

631 BRAWLEY SCHOOL RD STE 300, PMB 302
MOORESVILLE NC
28117-6204
US

V. Phone/Fax

Practice location:
  • Phone: 704-884-2060
  • Fax: 704-854-4860
Mailing address:
  • Phone: 704-360-4531
  • Fax: 704-360-2544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: KEVIN P OLIVER
Title or Position: CEO
Credential: MS
Phone: 704-491-0829