{
"Npi": {
"NPI": "1831264738",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "PHOENIX FAMILY COUNSELING & PLAY THERAPY CENTER, PLLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "4350 SNOW HILL DR.",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "GAINESVILLE",
"MailingAddressStateName": "VA",
"MailingAddressPostalCode": "20155",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "703-909-8963",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "7404 GALLERHER RD",
"SecondLinePracticeLocationAddress": "SUITE 100",
"PracticeLocationAddressCityName": "GAINESVILLE",
"PracticeLocationAddressStateName": "VA",
"PracticeLocationAddressPostalCode": "20155",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "703-909-8963",
"PracticeLocationAddressFaxNumber": "703-753-5193",
"EnumerationDate": "11/24/2006",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "SPOONER",
"AuthorizedOfficialFirstName": "MARY",
"AuthorizedOfficialMiddleName": "CATHERINE",
"AuthorizedOfficialTitle": "DIRECTOR",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "LCSW",
"AuthorizedOfficialTelephoneNumber": "703-909-8963",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "1041C0700X",
"TaxonomyName": "Clinical Social Worker",
"LicenseNumber": "0904003525",
"LicenseNumberStateCode": "VA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}