MEDICARE: PHOENIX RISING PROFESSIONAL COUNSELING, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	6401010792	MI
2	101YP2500X	Professional Counselor	6401010792	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1700049061	OTHER	MI	NPI NUMBER

General Provider Information

NPI Number	:	1447577101
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX RISING PROFESSIONAL COUNSELING, PC

Provider Business Mailing Address
First Line	:	PO BOX 26
Second Line	:
City	:	PAW PAW
State	:	MI
Zip	:	49079-0026
Country	:	US
Telephone Number	:	269-998-9696
Fax Number	:	269-415-0284

Provider Business Practice Location Address
First Line	:	302 WEST MICHIGAN AVENUE
Second Line	:
City	:	PAW PAW
State	:	MI
Zip	:	49079-0026
Country	:	US
Telephone Number	:	269-998-9696
Fax Number	:	269-415-0284

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. TODD CHRISTOPHER DAY
Credential	:	MA, LLPC, NCC
Telephone Number	:	269-998-9696

Provider Enumeration Date	:	04/21/2010
Last Update Date	:	04/21/2010

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