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General NPI Number Information
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NPI Number | 1386631786
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Entity Type | Organization
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Legal Business Name | PHOENIX PSYCHOLOGICAL & COUNSELING ASSOC INC
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Dates
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Enumeration Date | 09/30/2005
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | RT 20
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City | QUIET DELL
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State | WV
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Zip | 26408
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Country | US
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Telephone | 304-622-6404
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Fax | 304-622-6404
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Provider Business Mailing Address
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Address Line | 4579 BUCKHANNON PIKE STE 101
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City | MOUNT CLARE
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State | WV
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Zip | 26408-7176
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Country | US
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Telephone | 304-622-6404
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Fax | 304-622-6404
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Authorized Official
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Title or Position | OWNER
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Name | MR. CHARLES MCCLURE GREEN
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Credential |
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Telephone | 304-622-6404
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State | WV
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Taxonomy #2
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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 | WV
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Taxonomy #3
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State | WV
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