=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437635661
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIX PROFESSIONAL ADVISORS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2018
-----------------------------------------------------
Last Update Date | 12/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10022 WATER WORKS LN
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33578-5301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-933-0999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8939 TURNSTONE HAVEN PL
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33619-0826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-325-2610
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR THERAPIST
-----------------------------------------------------
Name | SAMANTHA WATERS
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 866-933-0999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | IMH14504
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------