Provider Demographics
NPI:1114756475
Name:PHOENIX RISING BEHAVIORAL SERVICES LLC
Entity type:Organization
Organization Name:PHOENIX RISING BEHAVIORAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD CERTIFIED BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALDON
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LBA
Authorized Official - Phone:512-761-6775
Mailing Address - Street 1:12638 RIDGELINE BLVD APT 6304
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-1212
Mailing Address - Country:US
Mailing Address - Phone:254-677-5011
Mailing Address - Fax:
Practice Address - Street 1:12638 RIDGELINE BLVD APT 6304
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-1212
Practice Address - Country:US
Practice Address - Phone:512-761-6775
Practice Address - Fax:737-367-3007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-26
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty