Provider Demographics
NPI:1285148874
Name:PHOENIX COUNSELING AND SUPPORT SERVICES
Entity type:Organization
Organization Name:PHOENIX COUNSELING AND SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:HALSTEAD
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LGSW
Authorized Official - Phone:304-806-2273
Mailing Address - Street 1:4855 MACCORKLE AVE SW STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1331
Mailing Address - Country:US
Mailing Address - Phone:304-806-2273
Mailing Address - Fax:
Practice Address - Street 1:4855 MACCORKLE AVE SW STE 200
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1331
Practice Address - Country:US
Practice Address - Phone:304-806-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16-121101YA0400X
WVBP00942576104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty