Provider Demographics
NPI:1992125553
Name:THE PHOENIX RECOVERY CENTER LLC
Entity type:Organization
Organization Name:THE PHOENIX RECOVERY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-438-3185
Mailing Address - Street 1:9980 S 300 W STE 105
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-3641
Mailing Address - Country:US
Mailing Address - Phone:801-438-3185
Mailing Address - Fax:801-438-3184
Practice Address - Street 1:489 W. SOUTH JORDAN PARKWAY
Practice Address - Street 2:STE 400
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095
Practice Address - Country:US
Practice Address - Phone:801-438-3185
Practice Address - Fax:801-438-3184
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE PHOENIX RECOVERY CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-22
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5549101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X, 103K00000X, 261QM0850X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty