Provider Demographics
NPI:1396883955
Name:PHOENIX COUNSELING SERVICES, INC.
Entity type:Organization
Organization Name:PHOENIX COUNSELING SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAM 'MIMS'
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPC
Authorized Official - Phone:865-548-7474
Mailing Address - Street 1:PO BOX 567
Mailing Address - Street 2:
Mailing Address - City:NORRIS
Mailing Address - State:TN
Mailing Address - Zip Code:37828-0567
Mailing Address - Country:US
Mailing Address - Phone:865-548-7474
Mailing Address - Fax:
Practice Address - Street 1:729 CHARLES SEIVERS
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716
Practice Address - Country:US
Practice Address - Phone:865-548-7474
Practice Address - Fax:865-494-9819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN298101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5441087Medicaid