Healthcare Provider Details

I. General information

NPI: 1205691755
Provider Name (Legal Business Name): PHOENIX RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2024
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 N SHERMAN AVE STE B15
MADISON WI
53704-4445
US

IV. Provider business mailing address

621 N SHERMAN AVE STE B17
MADISON WI
53704-4445
US

V. Phone/Fax

Practice location:
  • Phone: 608-893-1050
  • Fax: 608-893-1503
Mailing address:
  • Phone: 608-893-1050
  • Fax: 608-893-1503

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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. KIMBERLY J LOHMAN
Title or Position: CO-FOUNDER
Credential: MS LPC CSAC
Phone: 608-893-1050