Provider Demographics
NPI:1891524930
Name:PHOENIX NEUROPSYCHOLOGY AND COUNSELING CENTER
Entity type:Organization
Organization Name:PHOENIX NEUROPSYCHOLOGY AND COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHANTEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OKEWOLE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:602-391-0044
Mailing Address - Street 1:382 CARRIAGE HOUSE DR STE D
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2299
Mailing Address - Country:US
Mailing Address - Phone:602-391-0044
Mailing Address - Fax:
Practice Address - Street 1:382 CARRIAGE HOUSE DR STE D
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2299
Practice Address - Country:US
Practice Address - Phone:602-391-0044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-29
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty