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General NPI Number Information
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NPI Number | 1740065713
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Entity Type | Organization
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Legal Business Name | PHOENIX PLACE
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Dates
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Enumeration Date | 08/29/2023
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Last Update Date | 05/07/2024
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Provider Practice Location Address
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Address Line | 2012 W CHESTNUT ST
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City | LOUISVILLE
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State | KY
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Zip | 40203-1542
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Country | US
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Telephone | 502-656-9261
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Fax |
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Provider Business Mailing Address
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Address Line | 2012 W CHESTNUT ST
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City | LOUISVILLE
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State | KY
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Zip | 40203-1542
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Country | US
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Telephone | 502-656-9261
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DIAMOND CALLOWAY
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Credential |
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Telephone | 502-656-9261
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 #2
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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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Taxonomy #3
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 3245S0500X
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Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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