Healthcare Provider Details

I. General information

NPI: 1841110947
Provider Name (Legal Business Name): FYREBIRD RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2026
Last Update Date: 07/18/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4924 HIGHWAY 17 BYP S UNIT J
MYRTLE BEACH SC
29588-1605
US

IV. Provider business mailing address

4924 HIGHWAY 17 BYP S UNIT J
MYRTLE BEACH SC
29588-1605
US

V. Phone/Fax

Practice location:
  • Phone: 843-691-0074
  • Fax:
Mailing address:
  • Phone: 843-691-0074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: AZHANE POWELL
Title or Position: EXECUTIVE DIRECTOR
Credential: LISW-CP
Phone: 518-375-0904