Healthcare Provider Details

I. General information

NPI: 1891524930
Provider Name (Legal Business Name): PHOENIX NEUROPSYCHOLOGY AND COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 CARRIAGE HOUSE DR STE D
JACKSON TN
38305-2299
US

IV. Provider business mailing address

382 CARRIAGE HOUSE DR STE D
JACKSON TN
38305-2299
US

V. Phone/Fax

Practice location:
  • Phone: 602-391-0044
  • Fax:
Mailing address:
  • Phone: 602-391-0044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: CHANTEL OKEWOLE
Title or Position: CEO
Credential: PSYD
Phone: 602-391-0044