MEDICARE: PHOENIX COUNSELING, 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1992445977
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX COUNSELING, LLC

Provider Business Mailing Address
First Line	:	3618 CANYON LAKE DR STE 107
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-3129
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3618 CANYON LAKE DR STE 107
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-3129
Country	:	US
Telephone Number	:	712-540-7182
Fax Number	:

Authorized Official
Title or Position	:	COUNSELOR
Name	:	EMILY LAKE
Credential	:	LPC
Telephone Number	:	712-540-7182

Provider Enumeration Date	:	03/29/2022
Last Update Date	:	03/29/2022

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