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General NPI Number Information
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NPI Number | 1417479056
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Entity Type | Organization
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Legal Business Name | PHOENIX RISINGS COUNSELING CENTER LLC
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Dates
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Enumeration Date | 07/14/2017
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Last Update Date | 08/21/2017
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Provider Practice Location Address
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Address Line | 50 UNION AVE STE 804B
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City | IRVINGTON
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State | NJ
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Zip | 07111-5221
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Country | US
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Telephone | 770-568-0619
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Fax | 973-629-1741
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Provider Business Mailing Address
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Address Line | PO BOX 358
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City | SOUTH ORANGE
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State | NJ
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Zip | 07079-0358
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Country | US
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Telephone | 770-568-0619
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Fax | 973-629-1741
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | LYNNE CHANTEL HOLLEY
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Credential | LCSW LCADC
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Telephone | 973-393-0312
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 37LC00259900
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License Number State | NJ
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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 | 44SC05717900
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License Number State | NJ
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