Provider Demographics
NPI:1194411496
Name:RISING PHOENIX HEALTH AND WELLNESS EMPOWERMENT CENTER, LLC
Entity type:Organization
Organization Name:RISING PHOENIX HEALTH AND WELLNESS EMPOWERMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:404-200-7754
Mailing Address - Street 1:1543 LILBURN STONE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-1851
Mailing Address - Country:US
Mailing Address - Phone:404-200-7754
Mailing Address - Fax:
Practice Address - Street 1:2395 WALL ST SE STE 170
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-6703
Practice Address - Country:US
Practice Address - Phone:404-200-7754
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-11
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty