=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538811435
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIX COUNSELING SERVICE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2022
-----------------------------------------------------
Last Update Date | 02/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8909 REGENTS PARK DR STE 420
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33647-3432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-389-1816
-----------------------------------------------------
Fax | 352-389-1119
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7281 SUNSHINE GROVE RD STE 101
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34613-6800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-389-1816
-----------------------------------------------------
Fax | 352-389-1119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | KEIRA THOMAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-956-5059
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------