Healthcare Provider Details

I. General information

NPI: 1548555873
Provider Name (Legal Business Name): PHOENIX COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 N WASHINGTON ST
SHELBY NC
28150-3810
US

IV. Provider business mailing address

2505 COURT DR
GASTONIA NC
28054-2140
US

V. Phone/Fax

Practice location:
  • Phone: 704-751-3693
  • Fax:
Mailing address:
  • Phone: 704-921-3070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMHL-023-171
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: KEVIN P OLIVER
Title or Position: CEO
Credential:
Phone: 704-921-3070