Provider Demographics
NPI:1154381671
Name:CROSSROADS FAMILY COUNSELING CENTER, LLC
Entity type:Organization
Organization Name:CROSSROADS FAMILY COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:FRYE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:623-680-3486
Mailing Address - Street 1:39737 N HIGH NOON WAY
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-2376
Mailing Address - Country:US
Mailing Address - Phone:623-551-9234
Mailing Address - Fax:
Practice Address - Street 1:4614 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3081
Practice Address - Country:US
Practice Address - Phone:602-316-7134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-12149101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty