MEDICARE: PHEONIX MENTAL HEALTH 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	101Y00000X	Counselor	0701001079	VA

General Provider Information

NPI Number	:	1982043170
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHEONIX MENTAL HEALTH SERVICES, LLC

Provider Business Mailing Address
First Line	:	810 KEMPSVILLE RD
Second Line	:	SUITE 6
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-2723
Country	:	US
Telephone Number	:	757-619-2984
Fax Number	:

Provider Business Practice Location Address
First Line	:	810 KEMPSVILLE RD
Second Line	:	SUITE 6
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-2723
Country	:	US
Telephone Number	:	757-619-2984
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. ROSEMARY A THOMPSON
Credential	:	ED.D.,LPC
Telephone Number	:	757-619-2984

Provider Enumeration Date	:	06/20/2013
Last Update Date	:	06/20/2013

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