Provider Demographics
NPI:1679937932
Name:PHOENIX COUNSELING CENTER
Entity type:Organization
Organization Name:PHOENIX COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:704-491-0829
Mailing Address - Street 1:631 BRAWLEY SCHOOL RD
Mailing Address - Street 2:STE 300, PMB 302
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 1:609 E CENTER AVE
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2547
Practice Address - Country:US
Practice Address - Phone:704-884-2060
Practice Address - Fax:704-854-4860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301469Medicaid