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General NPI Number Information
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NPI Number | 1720572043
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Entity Type | Organization
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Legal Business Name | PHOENIX WELLNESS CENTER LLC
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Dates
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Enumeration Date | 06/20/2018
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Last Update Date | 06/21/2018
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Provider Practice Location Address
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Address Line | 2060 W WHISPERING WIND DR STE 270
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City | PHOENIX
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State | AZ
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Zip | 85085
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Country | US
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Telephone | 480-653-8434
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Fax | 623-258-4077
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Provider Business Mailing Address
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Address Line | 2060 W WHISPERING WIND DR STE 270
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City | PHOENIX
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State | AZ
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Zip | 85085-2869
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Country | US
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Telephone | 480-653-8434
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Fax | 623-258-4077
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | TONYA KINNAMAN
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Credential | MA, NCC, LPC
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Telephone | 480-653-8434
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 |
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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