=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639910003
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE PHOENIX COUNSELING AND RECOVERY PROJECT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2024
-----------------------------------------------------
Last Update Date | 12/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3441 COLONIAL BLVD STE 2
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33966-1121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-268-0000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4121 SW 9TH AVE
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33914-5714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-286-0000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | AMANDA A MAIKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 239-286-0000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------