Provider Demographics
NPI:1053168393
Name:PHOENIX THERAPY LLC
Entity type:Organization
Organization Name:PHOENIX THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:SHANATAI
Authorized Official - Last Name:MITCHELL-BRIVETT
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:203-898-4265
Mailing Address - Street 1:31 HAWTHORNE AVE
Mailing Address - Street 2:DERBY
Mailing Address - City:CT
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1101
Mailing Address - Country:US
Mailing Address - Phone:800-820-8210
Mailing Address - Fax:
Practice Address - Street 1:422 HIGHLAND AVENUE
Practice Address - Street 2:BUILDING C SUITE 1
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-2526
Practice Address - Country:US
Practice Address - Phone:800-820-8210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty