MEDICARE: PHOENIX COUNSELING AND RECOVERY SERVICES, LLC

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	LCAS-22298	NC

General Provider Information

NPI Number	:	1477065415
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX COUNSELING AND RECOVERY SERVICES, LLC

Provider Business Mailing Address
First Line	:	405 BATTLEGROUND AVE STE 203
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27401-2153
Country	:	US
Telephone Number	:	335-550-4558
Fax Number	:

Provider Business Practice Location Address
First Line	:	1102 KINDLEY ST
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27406-4213
Country	:	US
Telephone Number	:	336-458-7135
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MISS SARDIE ROCHELLE IZZARD
Credential	:	LCAS-A, LCSW-A
Telephone Number	:	336-550-4558

Provider Enumeration Date	:	10/31/2017
Last Update Date	:	03/28/2024

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