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General NPI Number Information
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NPI Number | 1134759186
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Entity Type | Organization
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Legal Business Name | PHOENIX REBELLION THERAPY, LLC
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Dates
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Enumeration Date | 01/17/2020
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Last Update Date | 01/18/2023
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Provider Practice Location Address
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Address Line | 4516 S 700 E STE 360
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City | MURRAY
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State | UT
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Zip | 84107-8317
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Country | US
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Telephone | 385-231-8387
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Fax | 385-240-3843
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Provider Business Mailing Address
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Address Line | 4516 S 700 E STE 360
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City | MURRAY
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State | UT
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Zip | 84107-8317
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Country | US
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Telephone | 385-231-8387
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/EXEC DIRECTOR
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Name | ROD WALLER
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Credential |
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Telephone | 385-231-8387
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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