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General NPI Number Information
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NPI Number | 1245765874
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Entity Type | Individual
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Provider Name | PHOENIX MUSSALOW MA, LPC, NCC
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Gender | Female
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Dates
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Enumeration Date | 04/20/2017
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Last Update Date | 08/06/2020
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Provider Practice Location Address
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Address Line | 2562 GRAHAM RD
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City | STOW
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State | OH
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Zip | 44224-3504
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Country | US
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Telephone | 276-200-8769
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Fax |
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Provider Business Mailing Address
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Address Line | 6693 N CHESTNUT ST STE 235
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City | RAVENNA
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State | OH
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Zip | 44266-3900
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Country | US
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Telephone | 330-296-3700
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | C.1600825
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License Number State | OH
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