Healthcare Provider Details

I. General information

NPI: 1225595689
Provider Name (Legal Business Name): ROSLYN PHENIX PHD LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 PURINGTON AVE
FORT WORTH TX
76103-2435
US

IV. Provider business mailing address

2623 EASOM CIR APT 250
ARLINGTON TX
76006-4120
US

V. Phone/Fax

Practice location:
  • Phone: 682-235-4807
  • Fax:
Mailing address:
  • Phone: 832-754-4943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number15227
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: