Healthcare Provider Details

I. General information

NPI: 1386631786
Provider Name (Legal Business Name): PHOENIX PSYCHOLOGICAL & COUNSELING ASSOC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RT 20
QUIET DELL WV
26408
US

IV. Provider business mailing address

4579 BUCKHANNON PIKE STE 101
MOUNT CLARE WV
26408-7176
US

V. Phone/Fax

Practice location:
  • Phone: 304-622-6404
  • Fax: 304-622-6404
Mailing address:
  • Phone: 304-622-6404
  • Fax: 304-622-6404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateWV

VIII. Authorized Official

Name: MR. CHARLES MCCLURE GREEN
Title or Position: OWNER
Credential:
Phone: 304-622-6404