MEDICARE: PHOENIX RISING THERAPY CENTER

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	101YM0800X	Mental Health Counselor
2	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1770142051
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX RISING THERAPY CENTER

Provider Business Mailing Address
First Line	:	2520 SAINT ROSE PKWY STE 221
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89074-7789
Country	:	US
Telephone Number	:	702-376-5842
Fax Number	:

Provider Business Practice Location Address
First Line	:	2520 SAINT ROSE PKWY STE 221
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89074-7789
Country	:	US
Telephone Number	:	702-376-5842
Fax Number	:

Authorized Official
Title or Position	:	CO-FOUNDER
Name	:	GEMMA GRACE RIVERA
Credential	:	LMFT, LCPC, LCADC
Telephone Number	:	702-379-6645

Provider Enumeration Date	:	06/10/2019
Last Update Date	:	06/10/2019

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