Provider Demographics
NPI:1902074768
Name:PHOENIX COUNSELING CENTER
Entity type:Organization
Organization Name:PHOENIX COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MPA
Authorized Official - Phone:704-491-0829
Mailing Address - Street 1:631 BRAWLEY SCHOOL RD
Mailing Address - Street 2:SUITE 200B, PMB 301
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-6204
Mailing Address - Country:US
Mailing Address - Phone:704-360-4531
Mailing Address - Fax:704-360-2544
Practice Address - Street 1:510 S ASPEN ST
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-2735
Practice Address - Country:US
Practice Address - Phone:704-735-7719
Practice Address - Fax:704-921-3066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NC251B00000X, 251S00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health