Provider Demographics
NPI:1992261853
Name:RISING PHOENIX WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:RISING PHOENIX WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICSW
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:AYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-502-6433
Mailing Address - Street 1:22 FRONT ST STE F
Mailing Address - Street 2:
Mailing Address - City:COUPEVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98239-3443
Mailing Address - Country:US
Mailing Address - Phone:360-672-8303
Mailing Address - Fax:
Practice Address - Street 1:22 FRONT ST STE F
Practice Address - Street 2:
Practice Address - City:COUPEVILLE
Practice Address - State:WA
Practice Address - Zip Code:98239-3443
Practice Address - Country:US
Practice Address - Phone:360-672-8303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-15
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty