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NPI Code Detail

MEDICARE: PHOENIX RISING WELLNESS CENTER OF CORPUS CHRISTI, PLLC

MEDICARE: PHOENIX RISING WELLNESS CENTER OF CORPUS CHRISTI, PLLC
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
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1659950343
Entity Type Code : Organization
Provider Name (Legal Business Name) : PHOENIX RISING WELLNESS CENTER OF CORPUS CHRISTI, PLLC
Provider Business Mailing Address
First Line : PO BOX 181459
Second Line :
City : CORPUS CHRISTI
State : TX
Zip : 78480-1459
Country : US
Telephone Number : 361-739-1679
Fax Number : 361-239-4286
Provider Business Practice Location Address
First Line : 5934 S STAPLES ST STE 230
Second Line :
City : CORPUS CHRISTI
State : TX
Zip : 78413-3800
Country : US
Telephone Number : 361-739-1679
Fax Number : 361-239-4286
Authorized Official
Title or Position : OWNER
Name : JAMES P IKONOMOPOULOS
Credential : PH-D, LPC
Telephone Number : 361-425-4684
Provider Enumeration Date : 04/07/2021
Last Update Date : 06/04/2026

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