Provider Demographics
NPI:1154932473
Name:PHOENIX COUNSELING AND WELLNESS, LLC
Entity type:Organization
Organization Name:PHOENIX COUNSELING AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL THERAPIST/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:NASHELLE
Authorized Official - Last Name:LOCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MSSA, LSW
Authorized Official - Phone:440-571-5009
Mailing Address - Street 1:35104 EUCLID AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-4566
Mailing Address - Country:US
Mailing Address - Phone:440-571-5009
Mailing Address - Fax:440-571-4850
Practice Address - Street 1:35104 EUCLID AVE STE 306
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4566
Practice Address - Country:US
Practice Address - Phone:440-571-5009
Practice Address - Fax:440-571-4850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-11
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1497255343Medicaid