=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720966625
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIX RISING THERAPY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2025
-----------------------------------------------------
Last Update Date | 08/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7459 OLD HICKORY DR
-----------------------------------------------------
City | MECHANICSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23111-3631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-730-2348
-----------------------------------------------------
Fax | 804-207-8853
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7459 OLD HICKORY DR
-----------------------------------------------------
City | MECHANICSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23111-3631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-730-2348
-----------------------------------------------------
Fax | 804-207-8853
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. SANDRA JENKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-730-2348
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------